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Background Candida auris infections are an emerging global threat with poor clinical outcome, high mortality rate, high transmission rate and outbreak potential. The objective of this work is to describe a multidisciplinary approach towards the investigation and containment of a Candida auris outbreak and the preventive measures adopted in a resource limited setting. Methods This outbreak investigational study was conducted at a 1300-bedded tertiary care academic hospital in South India. The study included 15 adult inpatients with laboratory confirmed Candida auris isolates. The outbreak cluster was identified in adult patients admitted from September 2017 to 2019. The system response consisted of a critical alert system for laboratory confirmed Candida auris infection and multidisciplinary ‘Candida auris care team’ for patient management. The team implemented stringent Infection Prevention and Control (IPC) measures including patient cohorting, standardized therapy and decolonization, staff training, prospective surveillance and introduction of Candida auris specific care bundle. Results Two outbreak clusters were identified; first cluster occurring between October and November 2017 and the second cluster in May 2018. The cohorts consisted of 7 and 8 Candida auris positive patients in the first and second waves of the outbreak respectively with a total survival rate of 93% (14/15). Deployment of containment measures led to gradual decline in the incidence of adult Candida auris positive cases and prevented further cluster formation. Conclusions The sustained implementation of guideline and evidence-based IPC measures and training of healthcare workers for improving awareness on systematically following standardized protocols of Candida auris related IPC practices successfully contained Candida auris outbreaks at our hospital. This demonstrates the feasibility of establishing a multidisciplinary model and bundling of practices for preventing Candida auris outbreaks in a Low- and Middle-income country.

Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens necessitates the implementation of antimicrobial stewardship program (ASP) initiatives to support its rational prescription across healthcare settings. Our study aims to describe the change in the epidemiology of polymyxins and patient outcomes following the implementation of ASP at our institution. The antimicrobial stewardship program initiated in February 2016 at our 1300 bed tertiary care center involved post-prescriptive audits tracking polymyxin consumption and evaluating prescription appropriateness in terms of the right indication, right frequency, right drug, right duration of therapy and administration of the right loading dose (LD) and maintenance dose (MD). Among the 2442 polymyxin prescriptions tracked over the entire study period ranging from February 2016 to January 2020, the number of prescriptions dropped from 772 prescriptions in the pre-implementation period to an average of 417 per year during the post-implementation period, recording a 45% reduction. The quarterly patient survival rates had a significant positive correlation with the quarterly prescription appropriateness rates (r = 0.4774, p = 0.02), right loading dose (r = 0.5228, p = 0.015) and right duration (r = 0.4361, p = 0.04). Our study on the epidemiology of polymyxin use demonstrated favorable effects on the appropriateness of prescriptions and mortality benefits after successful implementation of antimicrobial stewardship in a real-world setting.

In many parts of the world, including in India, pharmacist roles in antimicrobial stewardship (AMS) programmes remain unexplored. We describe the evolution and effect of the role of adding clinical pharmacists to a multidisciplinary AMS at a tertiary care teaching hospital in Kerala, India. Through effective leadership, multidisciplinary AMS (February 2016) and antitubercular therapy (ATT) stewardship programmes (June 2017) were established. Clinical pharmacists were introduced as core members of the programmes, responsible for the operational delivery of key stewardship interventions. Pharmacy-led audit and feedback monitored the appropriateness of antimicrobial prescriptions and compliance to AMS/ATT recommendations. Between February 2016 and January 2017, 56% (742/1326) of antimicrobial prescriptions were appropriate, and 54% (318/584) of recommendations showed compliance. By the third year of the AMS, appropriateness increased to 80% (1752/2190), and compliance to the AMS recommendations to 70% (227/325). The appropriateness of ATT prescriptions increased from a baseline of 61% (95/157) in the first year, to 72% (62/86, June 2018–February 2019). The compliance to ATT recommendations increased from 42% (25/60) to 58% (14/24). Such a model can be effective in implementing sustainable change in low- and middle-income countries (LMICs) such as India, where the shortage of infectious disease physicians is a major impediment to the implementation and sustainability of AMS programmes.

Background: The surgical pathway remains a hard to reach, critical target for antimicrobial stewardship (AMS) and infection prevention and control (IPC) globally. We investigated the drivers for AMS and IPC across surgical teams, in two academic hospitals in South Africa (SA) and India. Methods: Between July 2018 and August 2019, we conducted an ethnographic study across cardiovascular and thoracic surgery (CVTS) and gastrointestinal surgery teams utilizing non-participant observations, face-to-face interviews, and in-depth case-studies. Data were analysed using an inductive-deductive approach, applying thematic framework informed by existing evidence. Observations totalling over 190 hours (138 India, 60 SA) included shadowing healthcare professionals (HCPs) attending daily ward activities and ward rounds. Patients (6 India, 7 South Africa), and HCPs (44 India, 61 SA) were interviewed. Six (4 India, 2 SA) patient case-studies were developed. Findings: Across surgical pathways, multiple steps in IPC and AMS include several key HCPs who have implicit roles. These existing roles of HCPs (including nurses, and senior surgeons) are overlooked as interventions target junior doctors, bypassing the critical roles of the wider range of HCPs. Critically, the ownership of decisions remains with the operating surgeons and entrenched hierarchies restrict the integration of other HCPs in IPC and AMS. Interpretation: IPC and AMS remain key priorities for safe surgery. Identifying the implicit existing roles in AMS and IPC is critical. Developing nurse leadership, empowering pharmacists and engaging surgical leads is essential for integrated care. Many lessons can be learnt from the integrated models of care in the ICU setting. Funding Statement: This study was funded by the Economic and Social Research Council (ESRC) as part of the Antimicrobial Cross Council initiative supported by the seven UK research councils, and the Global Challenges Research Fund (GCRF). Declaration of Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethics Approval Statement: Ethics approval for this study was granted by the University of Cape Town Human Research Ethics Committee (HREC ref. 499/2018) and the Amrita Hospital Institutional Research and Ethics Committee (IEC-AIMS-2018-INECONT-005A).

Background Antimicrobial resistance is a major public health threat internationally but, particularly in India. A primary contributing factor to this rise in resistance includes unregulated access to antimicrobials. Implementing antimicrobial stewardship programs (ASPs) in the acute hospital setting will help curb inappropriate antibiotic use in India. Currently, ASPs are rare in India but are gaining momentum. This study describes ASP implementation in a large, academic, private, tertiary care center in India. Methods An ASP was established in February 2016 consisting of an administrative champion, hospitalist, microbiologist, intensivist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The ASP tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with ASP recommendations. Defined daily dose (DDD) of drugs and cost of antimicrobials were compared between the pre-implementation phase (February 2015–January 2016) and post-implementation phase (February 2016–January 2017). Results Of 48 555 patients admitted during the post-implementation phase, 1020 received 1326 prescriptions for restricted antibiotics. Antibiotic therapy was appropriate in 56% (742) of the total patient prescriptions. A total of 2776 instances of “inappropriate” antimicrobial prescriptions were intervened upon by the ASP. Duration (806, 29%) was the most common reason for inappropriate therapy. Compliance with ASP recommendations was 54% (318). For all major restricted drugs, the DDD/1000 patient days declined, and there was a significant reduction in mean monthly cost by 14.4% in the post-implementation phase. Conclusions Implementation of a multidisciplinary antibiotic stewardship program in this academic, large, Indian hospital demonstrated feasibility and economic benefits.

Background Polymyxin B(PB) and Colistin (PE) use have increased in India due to emergence of resistant Gram-negative organisms. The Indian Council of Medical Research has identified carbapenems, polymyxins (PE and PB) as key antimicrobials which require restriction in hospitals. We describe epidemiology of PB and PE use following implementation of an Antibiotic Stewardship Program (ASP) in a 1300-bed, private, tertiary-care center in Southern India. Methods An ASP was established at Amrita Hospital in Feb 2016 consisting of an administrative champion, hospitalist, microbiologist, intensivist and 5 pharmacists. Institutional guidelines for polymyxins were established and disseminated. The ASP team performed daily post-prescriptive reviews, evaluated and tracked appropriateness of PB and PE use, including administration of a loading dose (LD), maintenance dose (MD), frequency, route and duration of therapy. ASP recommendations and compliance were recorded. Results During the 12-month study period (Feb ‘16-Jan ‘17), 348 patients received 295 PE and 94 PB courses. Mean age was 50 yrs and 73% were male. Patients on Medicine and Hematology/Oncology teams accounted for 42% of all prescriptions. The most common infections were bacteremia (34%), pneumonia (29%) and UTI (23%). Pathogens were recovered in 69% (269/389) of cases, Klebsiella pneumoniae 23% (90/389) and Acinetobacter baumanii11 % (45/389) were most common. 290 (75%) of polymyxin course were judged to be inappropriate (78% of PE and 22% of PB). The most frequent reasons for inappropriate therapy included incorrect frequency of administration (64% for PB and 58% for PE), inappropriate MD (60% for PB and 48% for PE) and wrong duration of therapy (54% for PE and 48% for PB). 95% of incorrect MD for both PE and PB were too low. The reasons for inappropriateness were similar for both polymyxins.While all inappropriate LD episodes for PB (n = 22 %) were due to lack of a LD, errors for PE (n = 34%) involved either omission of LD or administration of LD that was too low.ASP recommendations were made in 190 instances with 58% provider compliance. Conclusion Review of PB and PE use in our hospital indicates a high percentage of inappropriate use and highlights stewardship opportunities for improving care of patients with resistant infections. Disclosures K. S. Kaye, Xellia: Consultant, Consulting fee; Merck: Consultant and Grant Investigator, Consulting fee and Research support; The Medicines Company: Consultant and Grant Investigator, Consulting fee and Research support