APSIC dental infection prevention and control (IPC) guidelines.

BACKGROUND: The Asia Pacific Society of Infection Control launched the Infection Prevention and Control Guidelines in July 2022. This document describes the guidelines and recommendations for safe practices in dental setting. It aims to highlight practical recommendations in a concise format designed to assist dental facilities at Asia Pacific region in achieving high standards in infection prevention and control practices, staff and patient safety. METHOD: The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published international guidelines and recommendations relevant to each section. RESULTS: It recommends standard precautions as a minimal set of preventive measures to protect staff and prevent cross transmission. Surgical aseptic technique is recommended when procedures are technically complex and longer in duration. Only trained staff are eligible to conduct reprocessing of dental instruments. The design, layout of the dental facility are important factors for successful infection prevention. The facility should also have a Pandemic Preparedness Plan. CONCLUSIONS: Dental facilities should aim for excellence in infection prevention and control practices as this is part of patient safety. The guidelines that come with a checklist help dental facilities to identify gaps for improvement to reach this goal.

Failure of sterilization in a dental outpatient facility: Investigation, risk assessment, and management.

In 2017, an incident of failed sterilization of dental instruments occurred at a large dental outpatient facility in Singapore. We aim to describe findings of the investigation of the sterilization breach incident, factors related to risk of viral transmission to the potentially affected patients, and the contact tracing process, patient management, and blood test results at a 6-month follow-up. A full assessment of the incident was immediately carried out. The factors related to risk of viral transmission due to affected instruments were analyzed using 3 keys points: breached step(s) and scale of the incident, prevalence of underlying bloodborne diseases and immunity in the Singapore population, health status of potential source patients, and type of dental procedure performed, and health status of affected patients and type of dental procedure received. Up to 72 affected instrument sets were used in 714 potentially affected patients who underwent noninvasive dental procedures. The investigation revealed that there was a lapse in the final step of steam sterilization, resulting in the use of incompletely sterilized items. The assessment determined that there was an extremely low risk of bloodborne virus transmission of diseases to the patients. At the 6-month follow-up, there were no infected/colonized cases found related to the incident. Lapses in the sterilization process for medical and dental instruments can happen, but a risk assessment approach is useful to manage similar incidents. Quick response and proper documentation of the sterilization process can prevent similar incidents.

Improving surgical site infection prevention in Asia-Pacific through appropriate surveillance programs: Challenges and recommendation.

BACKGROUND: Surgical site infections (SSIs) represent a substantial clinical and economic burden on patients and the healthcare system. The prevention of SSIs entails surveillance activities which lead to effective mitigation strategies, which are lacking across Asia Pacific (APAC). This manuscript aims to document gaps and challenges across APAC that affect the undertaking of a successful SSI surveillance activities and to provide recommendations on overcoming such challenges. METHODS: A targeted literature review with relevance to APAC identified a series of salient points pertaining to SSI prevention guidelines, implementation, surveillance and outcomes, which was discussed in July 2019 at the APAC Surgical Site Infection Prevention Symposium. An expert panel, comprising eight multidisciplinary experts from APAC and the USA, subsequently amalgamated the key discussion points from the Symposium and their clinical experiences in developing this article. RESULTS: The barriers to implementing a successful and effective APAC SSI surveillance program were identified as: (a) lack of standardized definitions, reporting methodology and accountability, (b) lack of fiscal resources, (c) reporting variability and under-reporting, and (d) lack of safety culture. Implementing an effective surveillance program in APAC will require countries to develop a well-designed and robust surveillance plan and ensure adequate training for staffs involved. CONCLUSION: To improve SSI prevention in the region, it is imperative to encourage implementation of national programs with standardized methodologies and accountabilities. An ongoing APAC information exchange, including data and methodologies, will enable continuous learning within the APAC region.

Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia-Pacific Region.

INTRODUCTION: Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia-Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country's healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30-31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC. METHODS: The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention. RESULTS: The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability. CONCLUSIONS: Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.

Routine antiseptic baths and MRSA decolonization: diverse approaches across Singapore's acute-care hospitals.

To determine the variation in practices on meticillin-resistant Staphylococcus aureus (MRSA) surveillance and management of MRSA-colonized patients amongst 17 acute healthcare facilities in Singapore, the Ministry of Health convened a sharing session with Infection Prevention and Control Leads. All hospitals practised close to universal MRSA entry swabbing in keeping with national policy. There were, however, major variations in the response to both positive and negative surveillance swabs across facilities including the role of routine antiseptic bathing and MRSA decolonization. Most undertaking decolonization considered its role to be in 'bioburden reduction' rather than longer-term clearance.

Debate on MERS-CoV respiratory precautions: surgical mask or N95 respirators?

Since the emergence of Middle East respiratory syndrome coronavirus (MERS-CoV) in mid-2012, there has been controversy over the respiratory precaution recommendations in different guidelines from various international bodies. Our understanding of MERS-CoV is still evolving. Current recommendations on infection control practices are heavily influenced by the lessons learnt from severe acute respiratory syndrome. A debate on respiratory precautions for MERS-CoV was organised by Infection Control Association (Singapore) and the Society of Infectious Disease (Singapore). We herein discuss and present the evidence for surgical masks for the protection of healthcare workers from MERS-CoV.

The impact of multidrug resistance in healthcare-associated and nosocomial Gram-negative bacteraemia on mortality and length of stay: cohort study.

Multidrug-resistant Gram-negative bacteria (MDR-GNB) are an emerging public health threat. Accurate estimates of their clinical impact are vital for justifying interventions directed towards preventing or managing infections caused by these pathogens. A retrospective observational cohort study was conducted between 1 January 2007 and 31 July 2009, involving subjects with healthcare-associated and nosocomial Gram-negative bacteraemia at two large Singaporean hospitals. Outcomes studied were mortality and length of stay post-onset of bacteraemia in survivors (LOS). There were 675 subjects (301 with MDR-GNB) matching study inclusion criteria. On multivariate analysis, multidrug resistance was not associated with 30-day mortality, but it was independently associated with longer LOS in survivors (coefficient, 0.34; 95% CI, 0.21-0.48; p < 0.001). The excess LOS attributable to multidrug resistance after adjustment for confounders was 6.1 days. Other independent risk factors for higher mortality included male gender, higher APACHE II score, higher Charlson comorbidity index, intensive care unit stay and presence of concomitant pneumonia. Concomitant urinary tract infection and admission to a surgical discipline were associated with lower risk of mortality. Appropriate empirical antibiotic therapy was neither associated with 30-day mortality nor LOS, although the study was not powered to assess this covariate adequately. Our study adds to existing evidence that multidrug resistance per se is not associated with higher mortality when effective antibiotics are used for definitive therapy. However, its association with longer hospitalization justifies the use of control efforts.

Isolation of the first three cases of Clostridium difficile polymerase chain reaction ribotype 027 in Singapore.

INTRODUCTION: The incidence of Clostridium (C.) difficile infection (CDI) was on the rise from 2001 to 2006 in Singapore. Recent unpublished data suggests that its incidence had remained stable or decreased in most local public hospitals between 2006 and 2010. It is, however, not known if the polymerase chain reaction (PCR) ribotype 027 strains have been circulating, although reports suggest that this strain is emerging in Asia, with the first cases reported from Japan in 2007, as well as in Hong Kong and Australia in 2009. We initiated a culture-based surveillance to detect this epidemic strain in Singapore. METHODS: From September 2008 to December 2009, all non-duplicate toxin-positive stool samples from the three largest public hospitals in Singapore were collected for culture and further analysis. RESULTS: Out of the 366 samples collected, 272 viable isolates were cultured. Of these, 240 tested toxin-positive and ten tested positive for the binary toxin gene; 35 different PCR ribotypes were found. Three isolates that tested positive for binary toxin contained the same PCR ribotyping pattern as the C. difficile 027 control strain. All three had the 18-bp deletion and single nucleotide tcdC deletion at position 117. Susceptibility testing was performed, demonstrating susceptibility to erythromycin and moxifloxacin. CONCLUSION: We report the first three isolates of C. difficile 027 from Singapore. However, their susceptibility patterns are more consistent with the historical 027 strains. Rising CDI incidence may not be associated with the emergence of the epidemic 027 strain at this time.

Economic and clinical impact of nosocomial meticillin-resistant Staphylococcus aureus infections in Singapore: a matched case-control study.

We performed a prospective matched case-control study, with six-month follow-up for discharged subjects, to evaluate the direct clinical and financial impact of nosocomial meticillin-resistant Staphylococcus aureus (MRSA) infections in Singaporean hospitals. Consecutive nosocomial MRSA-infected cases at both tertiary public sector hospitals in Singapore were matched for age, specialty service, major surgical procedure (if applicable) and Charlson comorbidity index with up to two non-infected controls each. Chart reviews and subject interviews were performed during hospitalisation and also upon six months post-discharge for survivors. The outcomes analysed were: mortality, length of hospitalisation (LOS), healthcare-associated financial costs, and health-related quality of life. The last was evaluated via an interviewer-administered EuroQol-5D questionnaire on discharge, with conversion to a single health state summary index. Attributable outcomes were ascertained by conditional logistic and linear regression. There were 181 cases and 351 controls. MRSA infection was independently associated with in-hospital death [14.4% vs 1.4%; odds ratio (OR): 5.54; 95% confidence interval (CI): 1.63-18.79, P=0.006], longer LOS (median of 32 days vs 7 days; coefficient: 1.21; 95% CI: 1.02-1.40, P<0.001), higher hospitalisation costs (median of US$18,129.89 vs US$4,490.47; coefficient: 1.14; 95% CI: 0.93-1.35; P<0.001), higher post-discharge healthcare-associated financial costs (median of US$337.24 vs US$259.29; coefficient: 0.39; 95% CI: 0.06-0.72; P=0.021), and poorer health-related quality of life (coefficient: -0.14; 95% CI: -0.21 to -0.08; P<0.001). Outcomes were not significantly different between both hospitals. The attributable individual, institutional and societal impact of MRSA infections is considerable in Singapore. Preventing such infections will result in substantial improvements in patient outcomes and healthcare delivery.

Reducing antimicrobial resistance through appropriate antibiotic usage in Singapore.

Two alarming trends threaten the future utility of antimicrobial agents: rise of antimicrobial resistance and decline in development of new antibiotics. The continuing emergence and spread of antimicrobial-resistant microbes--a global public health issue--exacerbates the problem of paucity of new antimicrobial agents. Singapore's public sector hospitals currently have some of the highest rates of antimicrobial resistance worldwide, evolving with surprising speed over the past two decades. Because there was no systematic surveillance until fairly recently, this healthcare problem has not been emphasised. In contrast, it is difficult to assess the scale of antimicrobial resistance in the community in view of the lack of recent research, although indirect evidence suggests that this is also a source of concern. A panel comprising representatives from multiple professional healthcare societies was convened to address the issue of antimicrobial resistance in Singapore, focusing on the conservation of antibiotics against resistance. From a review of the medical literature, potentially successful strategies involve facilitating prudent and appropriate use of antimicrobial agents in tandem with other interventions in infection control. Presently, there is a lack of data on the appropriate use of antibiotics in Singapore. The recommendations of the panel are: The professions should look into ways and means to support systematic data collection on antibiotic use and appropriateness of use; The Ministry of Health should take a more active and positive role in regulating antibiotic usage; Hospitals should actively support effective antimicrobial stewardship programmes; Educators should coordinate programmes to give greater emphasis on appropriate antimicrobial prescription, and support good clinical practice; and, Local and regional branches of pharmaceutical companies should adopt the Pharmaceutical Research and Manufacturers of America's updated code of conduct on interactions with physicians as a step towards re-aligning the industry-physician relationship in the direction of educational and informational support.

Control of a hospital-wide vancomycin-resistant Enterococci outbreak.

BACKGROUND: To analyze control measures used to eradicate a large vancomycin-resistant Enterococci (VRE) outbreak in a nonendemic 1600-bed tertiary care institution. METHODS: In mid-March 2005, VRE Van B was isolated from 2 clinical samples from different wards. Despite such measures as screening patients sharing rooms with index cases and isolating VRE patients, 43 isolates from different wards were detected by the end of March 2005. To eradicate a hospital-wide outbreak, a coordinated strategy between March and June 2005 comprised (1) formation of a VRE task force, (2) hospital-wide screening, (3) isolation of carriers, (4) physical segregation of contacts, (5) surveillance of high-risk groups, (6) increased cleaning, (7) electronic tagging of VRE status, and (8) education and audits. This is a retrospective study of this multipronged approach to containing VRE. The adequacy of rectal swab sampling for VRE was assessed in a substudy of 111 patients. The prevalence of methicillin-resistant Staphylococcus aureus (MRSA)/VRE co-colonization or co-infection also was determined. RESULTS: A total of 19,574 contacts were identified. Between April and June 2005, 5095 patients were screened, yielding 104 VRE carriers, 54 of whom (52%) were detected in the first 2 weeks of hospital-wide screening. The initial positive yield of 11.4% of persons actively screened declined to 4.2% by the end of June 2005. Pulsed-field typing revealed 1 major clone and several minor clones among the 151 total VRE cases, including 4 clinical cases. Hospital-wide physical segregation of contacts from other patients was difficult to achieve in communal wards. Co-colonization or co-infection with MRSA, which was present in 52 of 151 cases (34%) and the indefinite electronic tagging of positive VRE status strained limited isolation beds. Analysis of 2 fecal or rectal specimens collected 1 day apart may detect at least 83% of VRE carriers. CONCLUSION: A multipronged strategy orchestrated by a central task force curbed but could not eradicate VRE. Control measures were confounded by hospital infrastructure and high MRSA endemicity.

An outbreak of multidrug-resistant Salmonella enterica subsp. enterica serotype Typhimurium, DT104L linked to dried anchovy in Singapore.

Multidrug-resistant Salmonella enterica subsp. enterica serotype Typhimurium DT104L was first reported in Singapore from mid-July to mid-October 2000. Salmonella strains isolated from clinical laboratories were submitted to a reference laboratory for serotyping, phage-typing and pulsed-field gel electrophoresis (PFGE) using XbaI restriction endonuclease. An epidemiological investigation was conducted to determine the source of infection and mode of transmission using a structured questionnaire. A total of 33 cases involving mainly infants and toddlers were detected in the 3-month long outbreak. The outbreak strain was of the R-type ACGSTSu, i.e. resistant to ampicillin, chloramphenicol, gentamicin, streptomycin, tetracycline and sulphonamide. PFGE showed all isolates had an indistinguishable pattern, indicating a common source of infection. Consumption of imported dried anchovy was found to be the vehicle of transmission after adjusting for all confounding variables in the case-control study using stepwise logistic regression (OR 25.6; 95% CI 3.9-167.9; P = 0.001). Imported dried seafood should be properly processed, packed, labelled, and thoroughly cooked to prevent transmission of multidrug-resistant S. Typhimurium.

Microsporidial keratoconjunctivitis in a healthy contact lens wearer without human immunodeficiency virus infection.

PURPOSE: To present a rare case of microsporidial keratoconjunctivitis in an otherwise healthy contact lens wearer without human immunodeficiency virus infection who responded to treatment with systemic albendazole and topical fumagillin. DESIGN: Interventional case report. METHOD: A cornea epithelial scraping from a man with unilateral keratoconjunctivitis previously treated with topical steroids was evaluated by modified trichome staining. MAIN OUTCOME MEASURES: The patient was evaluated for his symptoms, visual acuity, clinical observations, and pathologic examination of corneal scrapes. RESULTS: Modified trichome staining of an epithelial corneal scraping revealed pinkish to red organisms characteristic of microsporidia. Results of a human immunodeficiency virus (HIV) enzyme-linked immunosorbent assay test were negative. The symptoms of ocular discomfort and clinical signs of keratoconjunctivitis resolved after 2 months of treatment with albendazole and topical fumagillin. CONCLUSIONS: Ocular infection with microsporidia, although classically occurring in patients with HIV infection, may occur rarely in healthy individuals, especially if previously treated with systemic immune suppression or topical steroids. Microsporidial keratoconjunctivitis should be considered in the differential diagnosis of a contact lens wearer with atypical multifocal diffuse epithelial keratitis.

A nosocomial outbreak of multiresistant Acinetobacter baumannii originating from an intensive care unit.

An outbreak of a multiresistant Acinetobacter baumannii in February through September 1996 affected 103 patients in a regional hospital in Singapore. We describe the effectiveness of closure of the outbreak area and the importance of good teamwork in the management of the outbreak.

Epidemiological analysis of Salmonella enteritidis isolates in Singapore.

OBJECTIVES: Salmonella enteritidis is the most common non-typhoidal Salmonella species isolated in Singapore causing gastroenteritis and occasional bacteremia with secondary complications. The number of S. enteritidis isolates rose in 1993 and since then, it was the commonest Salmonella sp. isolated. In 1997, a total of 139 S. enteritidis was isolated and this comprised 19.2% of all non-typhoidal Salmonella sp. isolated. METHODS: We studied the antimicrobial susceptibilities, phage types and molecular epidemiology of 89 of these S. enteritidis strains. Fifty per cent were stool isolates whilst 33.3% were isolated from blood samples. RESULTS: All the isolates were susceptible to cephalothin, ceftriaxone, ciprofloxacin, aztreonam, gentamicin, amikacin, kanamycin, neomycin, streptomycin and nalidixic acid; whilst 75.3% were resistant to sulphonamide, 15.7% to tetracycline, 7.9% to co-trimoxazole, 6.7% to trimethoprim, 2.2% to ampicillin and 2.2% to chloramphenicol. The most frequent phage types were phage type 4 (64%), followed by phage type 1 (12.4%) and phage type 8 (2.2%). Seventy four of the 89 (83.1%) S. enteritidis isolates analysed by pulsed-field gel electrophoresis showed an indistinguishable pattern A when digested by restriction enzyme Xba I suggesting the presence of a predominant clone of S. enteritidis circulating in Singapore in 1997.

In vitro activity of moxifloxacin against local bacterial isolates.

INTRODUCTION: The emergence of resistance to common antimicrobials in bacteria has been increasingly reported in various countries. Empirical antimicrobial therapy of various infections would therefore need to be reviewed. The introduction of new fluoroquinolones has created an interest in the use of these as possible agents in the empirical treatment of respiratory tract infections. MATERIALS AND METHODS: The minimum inhibitory concentration (MIC) of the new fluoroquinolone, moxifloxacin, against 400 clinical bacterial isolates was determined by the E-test method. RESULTS: All Streptococcus pneumoniae isolates (penicillin sensitive or resistant) were susceptible to moxifloxacin. Similarly, both beta-lactamase and non beta-lactamase producing Haemophilus influenzae and Moraxella catarrhalis isolates were susceptible to moxifloxacin. As for Enterobacteriaceae, 88.6% of the isolates tested were susceptible to moxifloxacin with MIC < 8 mg/L, but resistance was noted for some of Proteus mirabilis, Klebsiella spp. and Escherichia coli. Enterococci and Acinetobacter baumannii were resistant to moxifloxacin, whilst the anaerobes tested were susceptible to moxifloxacin. CONCLUSION: Moxifloxacin has good in vitro activity against common organisms associated with community and nosocomial infections, with the exception of enterococci, methicillin-resistant Staphylococcus aureus and ciprofloxacin-resistant gram-negative bacteria. There was good anti-anaerobic activity against Bacteroides fragilis and Clostridum spp. Results of this study are consistent with other similar published in vitro studies.

Staphylococcus lugdunensis: report of first case of skin and soft tissue infection in Singapore.

We report the first case of skin and soft tissue infection due to Staphylococcus lugdunensis in Singapore. This is a coagulase negative Staphylococcus species known to cause a wide variety of more serious infections--brain abscess, sepsis, chronic osteomyelitis and infective endocarditis.

Sharps and needlestick injuries: the impact of hepatitis B vaccination as an intervention measure.

INTRODUCTION: This paper studies the epidemiology of sharps and needlestick injuries amongst health care workers and the effectiveness of intervention measures implemented at a regional hospital, Singapore. MATERIALS AND METHODS: A retrospective review of sharps and needlestick injuries among healthcare workers of a regional hospital at Singapore between 1992 and 1997. Various interventions namely education, policy changes and a hospital-wide hepatitis B immunisation programme were reviewed for effectiveness of programmes implementation. RESULTS: Of the 347 reported sharps and needlestick injuries, 45.7% occurred in the nursing staff, 25.1% medical staff, 7.5% health attendants, 5.2% hospital cleaners and 3.7% laboratory technicians. A steady rise in reporting was noted amongst the doctors from 1994 and this correlated with the implementation of educational talks given to new medical staff in May 1993. The number of healthcare workers with no previous history of hepatitis B immunisation decreased significantly from 17 in 1996 to 9 in 1997 (P < 0.001, odds ratio = 1.806 with 95% CI 1.443 to 2.261) after the implementation of the hospital-wide hepatitis B immunisation programme. CONCLUSIONS: Levels of awareness may contribute towards changes seen in the number of reporting of injuries. In our experience, we contend that education and appropriate policy changes towards easier reporting help to decrease sharps and needlestick injuries in healthcare workers. The hospital-wide hepatitis B immunisation programme helped to raise the immune status of the staff so as to reduce the costly prophylactic usage of hepatitis B immunoglobulin.