Clinical impact of endemic NDM-producing Klebsiella pneumoniae in intensive care units of the national referral hospital in Jakarta, Indonesia

OBJECTIVE: A prospective observational study was performed to assess the epidemiology and clinical impact of carbapenem-non-susceptible Klebsiella pneumoniae (CNKP) in intensive care units (ICUs) of the national referral hospital in Jakarta, Indonesia. MATERIALS/METHODS: Adult patients consecutively hospitalized for > 48 h in two ICUs of the national referral hospital were included from April until October 2013 and from April until August 2014. K. pneumoniae from clinical cultures and standardized screening of rectum and throat on admission, discharge and weekly if hospitalized > 7 days were collected. Environmental niches and healthcare workers (HCWs) were also screened. Susceptibility was determined phenotypically and the presence of carbapenemase genes by PCR. Raman spectroscopy as well as multiple-locus variable number tandem repeat analysis (MLVA) were used for typing. RESULTS: Twenty-two out of 412 (5.3%) patients carried CNKP on admission and 37/390 (9.5%) acquired CNKP during ICU stay. The acquisition rate was 24.7/1000 patient-days at risk. One out of 31 (3.2%) environmental isolates was a CNKP. None of the HCWs carried CNKP. Acquisition of CNKP was associated with longer ICU stay (adjusted Hazard Ratio: 2.32 [CI99: 1.35-3.68]). ICU survival was lower among patients with CNKP compared to patients with carbapenem-susceptible K. pneumoniae (aHR 2.57, p = 0.005). Ninety-six of the 100 (96%) CNKP isolates carried a carbapenemase gene, predominantly blaNDM. Raman typing revealed three major clusters among 48 Raman types identified, whereas MLVA distinguished six major clusters among a total of 30 different genotypes. CONCLUSIONS: NDM-producing CNKP are introduced into these ICUs and some strains expand clonally among patients and the environment, resulting in endemic CNKP. CNKP acquisition was associated with prolonged ICU stay and may affect ICU survival. TRIAL REGISTRATION: The study was registered at Netherlands Trial Register http://www.trialregister.nl. Candidate number: 23527, NTR number: NTR5541, NL number: NL5425 (https://www.trialregister.nl/trial/5424), Retrospectively registered: NTR: 22 December 2015

Epidemiology and characterisation of carbapenem-non-susceptible Pseudomonas aeruginosa in a large intensive care unit in Jakarta, Indonesia

The aim of this study was to describe the epidemiology and clinical impact of carbapenem-non-susceptible Pseudomonas aeruginosa (CNPA) in intensive care units (ICUs) of the national refer

High-Risk International Clones of Carbapenem-Nonsusceptible Pseudomonas aeruginosa Endemic to Indonesian Intensive Care Units

Infection control effectiveness evaluations require detailed epidemiological and microbiological data. We analyzed the genomic profiles of carbapenem-nonsusceptible Pseudomonas aeruginosa (CNPA) strains collected from two intensive care units (ICUs) in the national referral hospital in Jakarta, Indonesia, where a multifaceted infection control intervention was applied. We used clinical data combined with whole-genome sequencing (WGS) of systematically collected CNPA to infer the transmission dynamics of CNPA strains and to characterize their resistome. We found that the number of CNPA transmissions and acquisitions by patients was highly variable over time but that, overall, the rates were not significantly reduced by the intervention. Environmental sources were involved in these transmissions and acquisitions. Four high-risk international CNPA clones (ST235, ST823, ST375, and ST446) dominated, but the distribution of these clones changed significantly after the intervention was implemented. Using resistome analysis, carbapenem resistance was explained by the presence of various carbapenemase-encoding genes (blaGES-5, blaVIM-2-8, and blaIMP-1-7-43) and by mutations within the porin OprD. Our results reveal for the first time the dynamics of P. aeruginosa antimicrobial resistance (AMR) profiles in Indonesia and additionally show the utility of WGS in combination with clinical data to evaluate the impact of an infection control intervention. (This study has been registered at www.trialregister.nl under registration no. NTR5541).IMPORTANCE In low-to-middle-income countries such as Indonesia, work in intensive care units (ICUs) can be hampered by lack of resources. Conducting large epidemiological studies in such settings using genomic tools is rather challenging. Still, we were able to systematically study the transmissions of carbapenem-nonsusceptible strains of P. aeruginosa (CNPA) within and between ICUs, before and after an infection control intervention. Our data show the importance of the broad dissemination of the internationally recognized CNPA clones, the relevance of environmental reservoirs, and the mixed effects of the implemented intervention; it led to a profound change in the clonal make-up of CNPA, but it did not reduce the patients' risk of CNPA acquisitions. Thus, CNPA epidemiology in Indonesian ICUs is part of a global expansion of multiple CNPA clones that remains difficult to control by infection prevention measures

Patients Infected by Extended-Spectrum Beta-Lactamase Producing Klebsiella Pneumoniae: Risk Factors and Outcomes

Infections due to resistant bacteria including Extended-Spectrum Beta-Lactamase (ESBL) producing Klebsiella pneumoniae becomes the major health problem worldwide. The aim of this study is to understand the prevalence of ESBL producing K. pneumoniae in Intensive Care Unit (ICU) dr. Cipto Mangunkusumo National Hospital (CMNH) and also to understand the risk factors related to these bacteria and its correlation with patients' outcomes. This retrospective study using the sample from clinical isolates of ICU's patients in CMNH who were treated in 2011 and known to have an infection with the K. pneumoniae based on microbiological examination. Phenotypic confirmation for ESBL conducted using double disk synergy test (DDST) and patient's history of illness was traced through the medical record. From 35 patients infected by K. pneumoniae, 25 isolates were ESBL positive. Central venous catheter (CVC) utilization is found to be a probable risk factor in getting an infection by such bacteria. Infection by ESBL producing K. pneumoniae could prolong ICU stays more than 20 days. Infeksi oleh Klebsiella pneumoniae penghasil Extended-Spectrum Beta-Lactamase (ESBL): Faktor Risiko dan Luaran Klinis Infeksi yang disebabkan oleh bakteri resisten termasuk Klebsiella pneumoniae penghasil ExtendedSpectrum Beta-Lactamase (ESBL) saat ini menjadi masalah kesehatan utama di seluruh dunia. Tujuan penelitian ini adalah untuk mengetahui prevalensi K. pneumoniae penghasil ESBL di Intensive Care Unit (ICU) Rumah Sakit Umum Pusat Nasional dr. Cipto Mangunkusumo (RSUPNCM) serta mengetahui faktor risiko terkait infeksi oleh bakteri tersebut dan hubungannya dengan luaran klinis pasien. Penelitian ini merupakan suatu studi restrospektif pada isolat pasien ICU RSUPNCM yang dirawat pada tahun 2011 dan diketahui mengalami infeksi oleh bakteri K. pneumoniae berdasarkan pemeriksaan mikrobiologi. Uji konfirmasi fenotip ESBL dilakukan dengan teknik DDST dan data pasien ditelusuri pada rekam medik. Dari 35 pasien yang terinfeksi oleh K. pneumoniae, 25 isolat merupakan penghasil ESBL. Penggunaan kateter vena sentral dapat menjadi faktor risiko terinfeksi oleh K. pneumoniae penghasil ESBL dan infeksi oleh bakteri tersebut dapat memperpanjang lama rawat pasien di ICU hingga lebih dari 20 hari

HOSPITAL SOUNDSCAPE: ACOUSTICS EVALUATION IN NEONATAL INTENSIVE CARE UNIT (NICU) ROOM OF A NATIONAL HOSPITAL IN JAKARTA, INDONESIA

Acoustics comfort in a room is one of the most important building physics aspect that should be observed. in public spaces like hospital, especially in an intensive care unit such as NICU. Researches on the acoustic conditions of NICU in Indonesia are still limited. The acoustical study conducted in this research is using objective, subjective, and simulation methods based on soundscape concept with the concern on the nurse’s perception. This research was conducted at a national hospital in Jakarta. According to National Standardization Agency of Indonesia (SNI) and World Health Organization (WHO), the suitable sound pressure level (SPL) for noise in patient’s room is 35 dBA. From the study, it was found that the equivalent SPL value exceeded the standard. Soundscape in NICU can be improve with the addition of curtain on the incubator’s side, installation of glass partition, and ceiling absorber in the nurse station area. The result of simulation showed that the SPL in the room decreased with average value 8.9 dBA for sound source alarm ventilator and 8.2 dBA for sound source medical officer conversations. And the speech transmission index (STI) increased from “bad” to “good” range became “fair” to “excellent” range