surveillance of antibiotic resistance at sihanouk hospital center of hope (2007-2013) phe thong, md;...

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


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


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


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


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


Key pathogens (N=1249)

10

22%

78%

Gram Positive Gram Negative


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%


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


Resistance paterns of Klebsiella pneumoniae (2007-2013); n=82


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)


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.


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


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%


surveillance of antibiotic resistance at sihanouk hospital center of hope (2007-2013) phe thong, md;...

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