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1 Department of Infectious Diseases, Tan Tock Seng Hospital, 2 National Centre for Infectious Diseases, 3 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 4 Division of Infectious Diseases, University Medicine Cluster, National University Hospital, 5 Department of Infectious Diseases, Singapore General Hospital, 6 Department of Infectious Diseases, Changi General Hospital, 7 Infectious Diseases Care Pte Ltd, Mount Elizabeth Medical Centre, 8 The Novena Medical Specialists, Mount Elizabeth Novena Specialist Centre, 9 Department of Care and Counselling, Tan Tock Seng Hospital, 10Department of Pharmacy, Tan Tock Seng Hospital, 11Department of Pharmacy, Singapore General Hospital, 12Department of Pharmacy, National University Hospital, Singapore [ABSTRACT FROM AUTHOR]

Purpose: Containing the coronavirus disease 2019 (COVID-19) pandemic would require aggressive contact tracing and isolation of suspected or confirmed COVID-19 cases. Models in published literature have suggested that digital rather than manual contact tracing might be more effective in containing the pandemic. This article seeks to examine the forms of contact tracing that Singapore, a highly dense city-state, adopts with a focus on new innovations including the use of digital technology. Methods: An exploratory literature search in PubMed, MEDLINE and EMBASE for studies reviewing technological approaches and responses to COVID-19 was performed. Information published by national agencies was also analysed to ascertain how technology was utilised in contact tracing. Results: Contact tracing in Singapore is overseen by the Ministry of Health (MOH). COVID-19 cases are interviewed on their whereabouts during a backward and forward activity mapping process to identify close contacts. Extensive contact tracing even involving the police and serological tools have helped to establish links between cases and closed several local clusters. Examination of patient's digital footprint has helped in contact tracing. Other digital technology introduced includes SafeEntry and TraceTogether. SafeEntry is a cloud-based visitor registration system while TraceTogether is a mobile phone application which operates by exchanging anonymised identifiers between nearby phones via Bluetooth connection. Conclusion: Digital contact tracing is likely to expand and continue to complement human-based contact tracing for the current and future pandemics. However, at this juncture, it is not ready to replace the manual and meticulous work that only Singapore contact tracers can achieve. [ABSTRACT FROM AUTHOR]

Objectives: Owing to gene transposition and plasmid conjugation, New Delhi metallo-β-lactamase (NDM) is typically identified among varied Enterobacteriaceae species and STs. We used WGS to characterize the chromosomal and plasmid molecular epidemiology of NDM transmission involving four institutions in Singapore.Methods: Thirty-three Enterobacteriaceae isolates (collection years 2010-14) were sequenced using short-read sequencing-by-synthesis and analysed. Long-read single molecule, real-time sequencing (SMRTS) was used to characterize genetically a novel plasmid pSg1-NDM carried on Klebsiella pneumoniae ST147.Results: In 20 (61%) isolates, blaNDM was located on the pNDM-ECS01 plasmid in the background of multiple bacterial STs, including eight K. pneumoniae STs and five Escherichia coli STs. In six (18%) isolates, a novel blaNDM-positive plasmid, pSg1-NDM, was found only in K. pneumoniae ST147. The pSg1-NDM-K. pneumoniae ST147 clone (Sg1-NDM) was fully sequenced using SMRTS. pSg1-NDM, a 90 103 bp IncR plasmid, carried genes responsible for resistance to six classes of antimicrobials. A large portion of pSg1-NDM had no significant homology to any known plasmids in GenBank. pSg1-NDM had no conjugative transfer region. Combined chromosomal-plasmid phylogenetic analysis revealed five clusters of clonal bacterial NDM-positive plasmid transmission, of which two were inter-institution clusters. The largest inter-institution cluster involved six K. pneumoniae ST147-pSg1-NDM isolates. Fifteen patients were involved in transmission clusters, of which four had ward contact, six had hospital contact and five had an unknown transmission link.Conclusions: A combined sequencing-by-synthesis and SMRTS approach can determine effectively the transmission clusters of blaNDM and genetically characterize novel plasmids. Plasmid molecular epidemiology is important to understanding NDM spread as blaNDM-positive plasmids can conjugate extensively across species and STs. [ABSTRACT FROM AUTHOR]

This article focuses on a study, which describes the clinical characteristics and outcome of patients with severe melioidosis. According to the researchers melioidosis is an infectious disease caused by Burkholderia pseudomaliei. Burkholderia pseudomaliei is a soil organism that is endemic in many parts of South East Asia and northern Australia. An increase has been observed in the incidence of melioidosis in Singapore. Data shows that the overall mortality remains high, ranging from 19 to 60 percent with many of these patients dying in the ICU. It is shown in this study that the patients studied were usually middle aged and had underlying medical comorbidities, and diabetes mellittis was the major predisposing factor.

Abstract: Since the advent of combination antiretroviral therapy (ART), the mortality attributable to human immunodeficiency virus (HIV) infection has decreased by 80%. Newer antiretroviral agents are highly efficacious, have minimal side effects as compared to older drugs, and can be formulated as combination tablets to reduce patients' pill burden. Despite these advances, 680,000 people worldwide died of acquired immunodeficiency syndrome-related illnesses in 2020. The National ART and Monitoring Recommendations by the National HIV Programme have been created to guide physicians on the prescribing of ART based on the patients' needs. These recommendations are based on international guidelines and tailored to the local context and unique domestic considerations. We hoped that with the publication of these recommendations, the care of people living with HIV can be enhanced, bringing us closer to ending HIV in our lifetime., (Copyright © 2024 Copyright: © 2024 Singapore Medical Journal.)

As of 27 October 2020, there have been 57,980 confirmed cases of COVID-19 in Singapore, with 28 fatalities. To summarise the Singapore experience in managing and containing COVID-19 based on available published data and from relevant sources, a review of literature using research databases such as PubMed and OVID Medline, along with non-peer-reviewed articles and other sources, was conducted with the search terms 'COVID-19' and 'Singapore'. Research conducted in Singapore has provided insight into the clinical manifestations and period of infectivity of COVID-19, demonstrated evidence of pre-symptomatic transmission, linked infection clusters using serological tools, and highlighted aspects of hospital-based environmental contamination. It has also provided guidance for diagnostic testing and has described immune and virologic correlates with disease severity. Evidence of effectiveness of containment measures such as early border control, rigorous contact training, and calibrated social distancing measures have also been demonstrated. Singapore's multipronged strategy has been largely successful at containing COVID-19 and minimising fatalities, but the risk of re-emergence is high.

Background: We conducted a national point prevalence survey (PPS) to determine the prevalence of healthcare-associated infections (HAIs) and antimicrobial use (AMU) in Singapore acute-care hospitals., Methods: Trained personnel collected HAI, AMU, and baseline hospital- and patient-level data of adult inpatients from 13 private and public acute-care hospitals between July 2015 and February 2016, using the PPS methodology developed by the European Centre for Disease Prevention and Control. Factors independently associated with HAIs were determined using multivariable regression., Results: Of the 5415 patients surveyed, there were 646 patients (11.9%; 95% confidence interval [CI], 11.1%-12.8%) with 727 distinct HAIs, of which 331 (45.5%) were culture positive. The most common HAIs were unspecified clinical sepsis (25.5%) and pneumonia (24.8%). Staphylococcus aureus (12.9%) and Pseudomonas aeruginosa (11.5%) were the most common pathogens implicated in HAIs. Carbapenem nonsusceptibility rates were highest in Acinetobacter species (71.9%) and P. aeruginosa (23.6%). Male sex, increasing age, surgery during current hospitalization, and presence of central venous or urinary catheters were independently associated with HAIs. A total of 2762 (51.0%; 95% CI, 49.7%-52.3%) patients were on 3611 systemic antimicrobial agents; 462 (12.8%) were prescribed for surgical prophylaxis and 2997 (83.0%) were prescribed for treatment. Amoxicillin/clavulanate was the most frequently prescribed (24.6%) antimicrobial agent., Conclusions: This survey suggested a high prevalence of HAIs and AMU in Singapore's acute-care hospitals. While further research is necessary to understand the causes and costs of HAIs and AMU in Singapore, repeated PPSs over the next decade will be useful to gauge progress at controlling HAIs and AMU., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Scrub typhus is a major infectious threat in the Asia-Pacific region. We report an unusual case of scrub typhus in a patient in Singapore who presented with sepsis and acute respiratory distress syndrome but lacked the pathognomonic eschar. The patient recovered after appropriate diagnosis and doxycycline treatment. Rickettsial diseases should be included in the differential diagnosis of febrile illnesses in regions where the diseases are endemic, and absence of eschar should not be the criterion used to rule out scrub typhus.

Background: Patients with neutropenic fever after 4-7 days of broad-spectrum antibiotics are given antifungals empirically. This strategy may lead to over-treatment., Methods: Patients with hematological malignancies undergoing intensive chemotherapy or hematopoietic stem cell transplantation were randomized to two arms. Patients in the 'preemptive' arm had regular galactomannan (GM) assays, and received caspofungin, amphotericin or voriconazole (CAV) for persistent febrile neutropenia if they had two positive GM results, or a positive GM result and a computed tomography (CT) of the thorax suggestive of invasive pulmonary aspergillosis (IPA). Patients in the 'empirical' arm received CAV in accordance with established guidelines., Results: Of 27 episodes in the preemptive arm, two cases of IPA were picked up by monitoring. In six episodes, CAV was started despite persistently negative GM readings. One additional patient received CAV for a false-positive GM. Of 25 episodes in the empirical arm, CAV was started empirically in 10, one of whom had CT features of IPA. By intent-to-treat and evaluable-episode analyses, respectively, the preemptive approach saved 11% and 14% of patients from empirical antifungals. Twelve-week survival was 85.2% in the preemptive arm and 84% in the empirical arm., Conclusions: A preemptive approach may reduce empirical antifungal use without compromising survival in persistently febrile neutropenic patients., (Copyright © 2011 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Introduction: The influenza pandemic has generated much interest in the press and the medical world. We report our experience with 15 cases of severe novel influenza A H1N1 (2009) infections requiring intensive care. The aim of this review is to improve our preparedness for epidemics and pandemics by studying the most severely affected patients., Clinical Picture: During the epidemic, hospitals were required to provide data on all confirmed H1N1 cases admitted to an intensive care unit (ICU) to the Ministry of Health. We abstracted information from this dataset for this report. To highlight learning points, we reviewed the case notes of, and report, the fi ve most instructive cases., Treatment: There were 15 cases admitted to an ICU from July 4, 2009 to August 30, 2009. Two patients died., Conclusions: The lessons we wish to share include the following: preparedness should include having intermediate-care facilities that also provide single room isolation and skilled nursing abilities, stringent visitor screening should be implemented and influenza may trigger an acute myocardial infarction in persons with risk factors.

Introduction: Stenotrophomonas maltophilia is an emerging pathogen in nosocomial infections that may result in high mortality. S. maltophilia often present as part of a polymicrobial culture and it is not well established when treatment is indicated. We aimed to identify predictors of mortality in patients with positive cultures of S. maltophilia., Materials and Methods: A retrospective cohort study in a tertiary care medical centre was performed in 150 adult patients with positive cultures of S. maltophilia. Patients' demographics, underlying diseases, severity of illness, length of hospitalisation, prior antibiotic exposure, number/types of indwelling catheters, culture sites, and appropriateness of empiric therapy were collected. Logistic regression was used to determine the independent risk factor(s) for infection-attributed mortality., Results: Ninety-nine males and 51 females were studied. The mean (SD) age and APACHE II score of the patients were 61.9 (16.0) and 14.0 (6.1), respectively. The respiratory tract was the most frequent site (55.3%) where S. maltophilia was isolated. Infection-attributed mortality was observed in 22 of the 150 patients (14.7 %). Admission to ICU [Odds ratio (OR), 3.767; 95% confidence interval (CI), 1.277-11.116, P = 0.016], and delayed effective treatment (OR, 18.684; 95% CI, 4.050-86.188; P <0.001) were identified as independent risk factors for mortality., Conclusions: Predictors of mortality in patients with positive cultures of S. maltophilia were identified, which may guide clinicians in patient assessment and devising therapeutic decisions. Further studies are needed to validate our results.

Introduction: Vancomycin-resistant enterococcus (VRE) can cause serious infections in vulnerable, immunocompromised patients., Materials and Methods: In this article, we summarise current data on epidemiology, detection, treatment and prevention of VRE., Results: VRE was first isolated in Singapore in 1994 and until 2004 was only sporadically encountered in our public hospitals. After 2 outbreaks in 2004 and in 2005, VRE has become established in our healthcare institutions. Multiple studies have shown that VRE spreads mainly via contaminated hands, cloths and portable equipment carried by healthcare workers., Conclusions: Only a comprehensive programme (consisting of active surveillance, isolation of colonised/infected patients, strict adherence to proper infection control practices and anti-microbial stewardship) can limit the spread of these organisms. In addition to monitoring the compliance with traditional infection control measures, new strategies that merit consideration include pre-emptive isolation of patients in high-risk units and molecular techniques for the detection of VRE.

Should healthcare workers (HCWs) be routinely tested for HIV? The authors reviewed the literature on the risk and incidence of HIV transmission from HCW to patients and offer recommendations for HIV testing in HCWs in Singapore. Management of HCWs who are tested seropositive for HIV infection is also discussed in this paper.

Singapore reported the elimination of malaria in 1982, but this country remains vulnerable to imported malaria. We describe a large cluster of 16 cases of imported Plasmodium falciparum malaria in visiting Nigerian students. More than half were asymptomatic and diagnosed only on screening. Although early diagnosis and treatment of patients averted local transmission of disease, our report illustrates the vulnerability of malaria-free countries to the introduction of malaria in this age of increasing globalization and ease of travel.

Introduction: Until recently, vancomycin-resistant enterococcus (VRE) infection or colonisation was a rare occurrence in Singapore. The first major VRE outbreak involving a 1500-bed tertiary care institution in March 2005 presented major challenges in infection control and came at high costs. This study evaluates the predictors of VRE carriage based on patients' clinical and demographic profiles., Materials and Methods: Study patients were selected from the hospital inpatient census population during the VRE outbreak (aged 16 years or more). Clinical information from 84 cases and 377 controls were analysed., Results: Significant predictors of VRE carriage included: age>65 years Odds ratio (OR), 1.98; 95% CI (confidence interval), 1.14 to 3.43); female gender (OR, 2.15; 95% CI, 1.27 to 3.65); history of diabetes mellitus (OR, 1.94; 95% CI, 1.14 to 3.30), and staying in a crowded communal ward (OR, 2.75; 95% CI, 1.60 to 4.74). Each additional day of recent hospital stay also posed increased risk (OR, 1.03; 95% CI, 1.01 to 1.04)., Conclusion: Elderly diabetic females with prolonged hospitalisation in crowded communal wards formed the profile that significantly predicted VRE carriage in this major hospital-wide outbreak of VRE in Singapore. It is imperative that active VRE surveillance and appropriate infection control measures be maintained in these wards to prevent future VRE outbreaks.

We report the first outbreak of vancomycin-resistant Enterococcus faecium colonization and infection among inpatients in the hematology ward of an acute tertiary care public hospital in Singapore. Two cases of bacteremia and 4 cases of gastrointestinal carriage were uncovered before implementation of strict infection control measures resulted in control of the outbreak.

Introduction: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged worldwide. In contrast to healthcare-associated MRSA (HA-MRSA), CA-MRSA isolates are usually susceptible to multiple non-beta-lactam antibiotics and cause a distinct spectrum of infections in epidemiologically disparate populations - in particular, cutaneous abscesses, necrotising fasciitis and necrotising pneumonia. They arise from a broader genetic background, and possess differing virulence genes. We aim to describe the distribution of different molecular subtypes of CA-MRSA among various regions and discuss briefly the implications of CA-MRSA from a local perspective., Methods: Literature review of articles on CA-MRSA, focusing mainly on reports where the genetic background of isolates had been analysed using multi-locus sequence typing (MLST). Singapore data were obtained from the local CA-MRSA database., Results: MLST analysis demonstrated the presence of epidemic subtypes of CA-MRSA within most geographic areas. In parts of the United States, community MRSA infections currently exceed those caused by their methicillin-susceptible counterparts. In Singapore, CA-MRSA infections are increasing, predominantly as a result of the spread of ST30 clones., Conclusion: Available evidence suggests that the emergence of MRSA from the community is not going to be a transient phenomenon. Local guidelines for dealing with this phenomenon at both therapeutic and preventive levels are needed prior to the potential development of a situation mirroring that of meso-endemic HA-MRSA in local hospitals or CA-MRSA epidemics in parts of USA.

Analysis of hospital-acquired methicillin-resistant Staphylococcus aureus strains isolated from a tertiary public hospital in Singapore revealed that multisusceptible strains had gradually started to replace the endemic multiresistant strain (ST239-MRSA-III) since 2002. Molecular typing showed that this was a predominantly clonal outbreak of a UK-EMRSA-15 strain (ST22-MRSA-IV).

A study of the prevalence and epidemiology of Panton-Valentine leukocidin-producing Staphylococcus aureus in a tertiary public hospital was conducted. The incidence of gene carriage among S. aureus strains causing disease was 11.6%. Results were significant for the higher incidence of gene carriage, compared with those found in previous studies.

We describe a patient with severe acute respiratory syndrome (SARS) whose clinical symptoms were masked by Escherichia coli bacteremia. SARS developed in a cluster of healthcare workers who had contact with this patient. SARS was diagnosed when a chest infiltrate developed and when the patient's brother was hospitalized with acute respiratory failure. We highlight problems in atypical cases and offer infection control suggestions.