surveillance of antibiotic resistance at sihanouk hospital center of hope (2007-2013) phe thong, md;...
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Surveillance of Antibiotic Resistance atSihanouk Hospital Center of HOPE
(2007-2013)
Phe Thong, MD; Erika Vlieghe, MD PhD; Lim Kruy, MD; Veng Chhunheng, MD; Kham Chun, MLT; Sovan Ieng,
MD; Birgit De Smet, MSc; Jan Jacobs, MD PhD
Workshop on Biodiversity
Nov 17-18, 2014, USH, Phnom Penh
Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
Institute for Tropical Medicine (ITM), Antwerp, Belgium
Background• Bloodstream infection (BSI) is an important cause of
morbidity and mortality worldwide.• Early administration of adequate antibiotic therapy is
essential to improve outcome – based on knowledge of local bacterial pathogens and their
resistance patterns (Ibrahim 2000)
• In Cambodia, surveillance data on blood stream infections or other invasive infections are not widely available so far.
• 2005: Start microbiology laboratory services• 07/2007: Start surveillance of bloodstream infections (sepsis)2
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Materials and methods• Designs: Descriptive of surveillance data
• Systematic blood cultures: all patients presenting at SHCH with ‘Systemic Inflammatory Response Syndrome (SIRS)
• Sampling 10 ml blood (2 bottles)– Culture in BacTalert vials (bioMérieux, Marcy l'Etoile,
France)– Incubated for 7 days at 35°C– Visual inspection of the chromogenic growth indicator.
3
At least 2 of the following criteria:• Temperature > 38°C or <36°C • Pulse rate > 90/min • Respiratory rate >20/min • WBC >12,000/mm3 or <4,000/mm3
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Chromogenic growth indicator
4Thong Phe, Antibiotic surveillance in
SHCH 2007 - 2013
Materials and methods
• Identification to the species level: standard microbiological techniques
• Antibiotic susceptibilities: disk diffusion, breakpoints according to CLSI guidelines– Additional E-test (for penicillin susceptibility in S.
pneumoniae)– Additional double disk test for ESBL-screening
• External quality control (ITM Antwerp, Belgium)
5
* CLSI: Clinical and Laboratory Standards Institute.Thong Phe, Antibiotic surveillance in
SHCH 2007 - 2013
Data collection• Blood culture request form contains demographic and
basic clinical data• Microbiological laboratory data recorded in a laboratory
logbook.• Data entered and stored in the hospital electronic
database • Positive blood cultures: patients are traced, additional
data on treatment and outcome collected• A monthly report is made and communicated in the
hospital
6Thong Phe, Antibiotic surveillance in
SHCH 2007 - 2013
Results
• Between 7/2007 and 12/2013–14291 blood cultures samples received
from 10352 patients. • Sex: 54.1% female• Median age=45 years old (IQR=31 – 59)
–1249 clinically significant organisms (CSO)• Average yield 8.8 % • 90 % is community-acquired infection
7Thong Phe, Antibiotic surveillance in
SHCH 2007 - 2013
Number of bacterial culture; SHCH: 2007 - 2013
8
2007 2008 2009 2010 2011 2012 20130
1000
2000
3000
4000
5000
6000
7000
8000
729
4306
68136115
4132 4310
5259
496
16052240 2353 2248 2381
2968
Total cultureBlood culture
Results
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Positivity rate of blood culture
9
2007 2008 2009 2010 2011 2012 2013 20140
2
4
6
8
10
12
9.1 8.1 7.79
10.3 9.8 9.99.7
4 5.66.8 6.9
5.9 4.7 4.4
1.5
Percentage of CSO and contamination rate of blooc culture, SHCH
% CSO % contamination rateYears
Perc
enta
ge
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Key pathogens (N=1249)
10
22%
78%
Gram Positive Gram Negative
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Key pathogens (n=1249)
11
111
365
213
86
73
119
Staphylococcus aureus
Streptococcus pneumoniae
Other streptococcus sp
Enterococcus species
Other gram pos
Escherichia coli
Salmonella species
Klebsiella sp
Other Enterobacteriacea
Burkholderia pseudomallei
Pseudomonas species
Other Gram(-) non-fermentive
Other gram neg
OtherE. coli: 29%
S. aureus: 9%
Salmonella spp: 17%
Burkholderia pseudomallei: 10%
Klebsiella sp:7%
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Hospital outbreak of Burkholderia cepacia
Search for source of infection:- Connector of Bag of Ringer Lactate
grew B. cepacia- Bag of Ringer Lactate used for
flushing grew B. cepacia
De Smet et al. Clin Microbio Infect. 2013 Sep;19(9):832-7
Community Outbreak of Salmonella Paratyphi A
13
2007-2010: 2 cases in 4 year2011-2013: 83 cases in 3 years (74 cases in 2013!!)
Vlieghe, Eurosurveillance 2013Thong Phe, Antibiotic surveillance in
SHCH 2007 - 2013
14
Resistance patterns of Escherichia coli (E. coli)2007 – 2013; n=365
*Note: ESBL test available only from 2010
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Resistance paterns of Klebsiella pneumoniae (2007-2013); n=82
15Thong Phe, Antibiotic surveillance in
SHCH 2007 - 2013
*Note: ESBL test available only from 2010 Emergence of Carbapenema-producing Klebsiella pneumonia in our hospital.
Resistance patterns of Salmonella Typhi2008 – 2013; n=53
16
*DCS: Decrease ciprofloxacin susceptibility (Nalidixic acid resistance)Thong Phe, Antibiotic surveillance in
SHCH 2007 - 2013
17
MRSA
Linco
mycin
SMX/TPM
Ciproflo
xacin
Vanco
mycin
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2007 (n=4)2008 (n=13)2009 (n=19)2010 (n=20)2011 (n=23)2012 (n=17)2013 (n=14)Average (n=110)
Perc
enta
ge o
f res
ista
nce
Resistance Staphyloccocus aureus (SHCH; 2007 – 2013)
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Discussion and Conclusions• (Community-acquired) BSI among Cambodian adults
– mainly Gram negative organisms– predominantly E.coli, Salmonella sp. and B. pseudomallei.
• Surveillance helps also to discover outbreaks• High rate of antibiotic resistance especially gram negative
pathogens (E. coli)• Limitation: single hospital surveillance, possible population
selection bias.• Nation wide surveillance and control of antimicrobial
resistance and its driving forces is highly needed.
18Thong Phe, Antibiotic surveillance in
SHCH 2007 - 2013
Thanks to…
• All patients
• All staff and management of SHCH
• Our dedicated colleagues of the FA3 agreement project on Antibiotic Resistance– SHCH: Phe Thong, Heng Chhun Veng, Kruy Lim, Chun Kham,
Sopheak Thai, Elen Mailing, Syna Teav– ITM: Jan Jacobs, Erika Vlieghe, Birgit De Smet, Lut Lynen, Johan
van Griensven, Nathalie Lorent
• Funder: DGDC (Belgian government)19
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
Resistance Staphyloccocus aureus (SHCH; 2007 – 2013)
20
Years 2007 2008 2009 2010 2011 2012 2013 Average
N=110 4 13 19 20 23 17 14
MRSA 0% 15% 21% 25% 23% 53% 21% 26%
Lincomycin 0% 54% 42% 32% 64% 88% 79% 56%
SMX/TPM 25% 15% 17% 15% 14% 35% 15% 17%
Ciprofloxacin 0% 46% 16% 21% 32% 63% 31% 32%
Vancomycin 0% 0% 0% 0% 0% 0% 0% 0%
Thong Phe, Antibiotic surveillance in SHCH 2007 - 2013
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