Evidence for Community Transmission of Community-Associated but Not Health-Care-Associated Methicillin-Resistant Staphylococcus Aureus Strains Linked to Social and Material Deprivation: Spatial Analysis of Cross-sectional Data

Supporting information for a paper titled "Evidence for Community Transmission of Community-Associated but Not Health-Care-Associated Methicillin-Resistant Staphylococcus Aureus Strains Linked to Social and Material Deprivation: Spatial Analysis of Cross-sectional Data". This includes: an MS Word document that describes the modelling approach (S1 Methods), Summary statistics for area-level variables in 513 LSOAs within catchment areas of the hospital cohort (S1 Table), data from the 2011 England and Wales census that outlines population structure of 513 LSOAs within catchment areas of the hospital cohort. (S2 Table), Individual patient-level metadata (S1 Text), and LSOA-level aggregated metadata (S2 Text

Prospective surveillance of healthcare associated infections in a Cambodian pediatric hospital

Abstract Background Healthcare associated infections (HAI) are the most common preventable adverse events following admission to healthcare facilities. Data from low-income countries are scarce. We sought to prospectively define HAI incidence at Angkor Hospital for Children (AHC), a Cambodian pediatric referral hospital. Methods Prospective HAI surveillance was introduced for medical admissions to AHC. Cases were identified on daily ward rounds and confirmed using locally adapted Centers for Disease Control and Prevention (CDC) definitions. During the surveillance period, established infection prevention and control (IPC) activities continued, including hand hygiene surveillance. In addition, antimicrobial stewardship practices such as the creation of an antimicrobial guideline smartphone app were introduced. Results Between 1st January and 31st December 2015 there were 3,263 medical admissions and 102 HAI cases. The incidence of HAI was 4.6/1,000 patient-days (95% confidence interval 3.8\u20135.6) and rates were highest amongst neonates. Median length of stay was significantly longer in HAI cases: 25\ua0days versus 5\ua0days for non-HAI cases ( p \u2009<\u20090.0001). All-cause in-hospital mortality increased from 2.0 to 16.1% with HAI ( p \u2009<\u20090.0001). Respiratory infections were the most common HAI (54/102; 52.9%). Amongst culture positive infections, Gram-negative organisms predominated (13/16; 81.3%). Resistance to third generation cephalosporins was common, supporting the use of more expensive carbapenem drugs empirically in HAI cases. The total cost of treatment for all 102 HCAI cases combined, based on additional inpatient days, was estimated to be $299,608. Conclusions Prospective HAI surveillance can form part of routine practice in low-income healthcare settings. HAI incidence at AHC was relatively low, but human and financial costs remained high due to increased carbapenem use, prolonged admissions and higher mortality rates

Short course amphotericin B with high dose fluconazole for HIV-associated cryptococcal meningitis.

OBJECTIVE: To define more rapidly effective initial antifungal regimens sustainable in resource-constrained settings. METHODS: Cohort study in SW Uganda: Thirty HIV-seropositive, antiretroviral therapy-naïve, patients with first episode cryptococcal meningitis were treated with high dose fluconazole (1200 mg/d for 2 weeks, then 800 mg/d until ART started) plus amphotericin B (AmB, 1 mg/kg/d), with routine normal saline and potassium supplementation, for the initial 5 days. Outcome measures were early fungicidal activity (EFA), determined by serial quantitative CSF cultures, safety, and mortality. RESULTS: EFA was -0.30 ± 0.11 log CFU/day calculated over the first 2 weeks of treatment, with no reduction in the rate of clearance between days 5 and 14. There was no grade IV hypokalemia or elevated creatinine, and no grade III or IV anemia or elevation of ALT. AmB or high dose fluconazole were not stopped early in any patient. Mortality was 23% at 2, and 28% at 10 weeks. CONCLUSIONS: Short course AmB was associated with rapid clearance of infection and was well-tolerated, suggesting it could be used safely in many centres currently relying on fluconazole monotherapy. Phase III trials are needed in African centres to compare short course with the standard 2-week course of AmB

Clonal variation in high- and low-level phenotypic and genotypic mupirocin resistance of MRSA isolates in south-east London

OBJECTIVES: Both low-level mupirocin resistance (LMR) and high-level mupirocin resistance (HMR) have been identified. The aim of this study was to determine the epidemiology of LMR and HMR in MRSA isolates at five hospitals that have used mupirocin for targeted decolonization as part of successful institutional control programmes. METHODS: All MRSA identified in three microbiology laboratories serving five central and south-east London hospitals and surrounding communities between November 2011 and February 2012 were included. HMR and LMR were determined by disc diffusion testing. WGS was used to derive multilocus sequence types (MLSTs) and the presence of HMR and LMR resistance determinants. RESULTS: Prevalence of either HMR or LMR amongst first healthcare episode isolates from 795 identified patients was 9.69% (95% CI 7.72-11.96); LMR was 6.29% (95% CI 4.70-8.21) and HMR was 3.40% (95% CI 2.25-4.90). Mupirocin resistance was not significantly different in isolates identified from inpatients at each microbiology laboratory, but was more common in genotypically defined 'hospital' rather than 'community' isolates (OR 3.17, 95% CI 1.36-9.30, P = 0.002). LMR was associated with inpatient stay, previous history of MRSA and age ≥65 years; HMR was associated with age ≥65 years and residential postcode outside London. LMR and HMR varied by clone, with both being low in the dominant UK MRSA clone ST22 compared with ST8, ST36 and ST239/241 for LMR and with ST8 and ST36 for HMR. V588F mutation and mupA carriage had high specificity (>97%) and area under the curve (>83%) to discriminate phenotypic mupirocin resistance, but uncertainty around the sensitivity point estimate was large (95% CI 52.50%-94.44%). Mutations in or near the mupA gene were found in eight isolates that carried mupA but were not HMR. CONCLUSIONS: Mupirocin resistance was identified in <10% of patients and varied significantly by clone, implying that changes in clonal epidemiology may have an important role in determining the prevalence of resistance in conjunction with selection due to mupirocin use

Maps for RR of HA- and CA-MRSA in LSOAs compared to the whole catchment area, in ecological regression models accounting for area-specific quintile-stratified percentage of usual residents attending a hospital and households deprived in 2–4 dimensions (HA-MRSA) or 1–2 dimensions (CA- MRSA).

<p>Ecological regression models account for the distribution and effect of risk factors for MRSA in addition to the observed and expected counts of HA- or CA-MRSA given the standardised age and gender population structure in each LSOA. HA-MRSA (A) was modelled considering unstructured random effects only (iid model). CA-MRSA (B) was modelled considering both unstructured and structured (spatial) random effects (BYM model). Cut-off values in figure legends correspond to quantiles for area-specific RRs of HA- and CA-MRSA, respectively.</p

Maps for RR of HA- and CA-MRSA in LSOAs compared to the whole catchment area in disease mapping (unadjusted) models.

<p>Disease mapping models do not take into consideration the distribution and effect of risk factors for MRSA. These account for the observed and expected counts of HA- or CA-MRSA given the standardised age and gender population structure in each LSOA. HA-MRSA (A) was modelled considering unstructured random effects only (iid model). CA-MRSA (B) was modelled considering both unstructured and structured (spatial) random effects (BYM model). Cut-off values in figure legends correspond to quantiles for area-specific RRs of HA- and CA-MRSA, respectively.</p