Strategic measures for the control of surging antimicrobial resistance in Hong Kong and mainland of China

Cheng, Vincent CC; Wong, Sally CY; Ho, Pak-Leung; Yuen, Kwok-Yung

Proactive infection control measures must be in place to prevent nosocomial dissemination of MDROs, especially in the context of ongoing complicated MDRO transmission dynamic between hospitals and the community (Figure 4 ). For MDROs that are not yet endemic in hospitals, pro-active surveillance cultures allow for early recognition of patients with asymptomatic colonization of MDROs (Table 1) . In Hong Kong, we adopt the 'whom TO screen model' as previously described, 90, 91 where T represents a history of hospitalization outside Hong Kong (medical tourism) and O represents a history of receiving surgical operation outside Hong Kong within the preceding 12 months admission, especially in areas in mainland China where NDM-1-positive Enterobacteriaceae is reported. 11 However, travel history alone without contact with medical care may become a potential risk factor for acquisition of MDROs, as NDM-1-producing bacteria were found in 99 water samples collected from river water, treated drinking water, water samples from pools and sewage from 4 comprehensive hospitals in Beijing 92 and NDM-1 was identified in two of 50 drinking-water samples and 51 of 171 seepage samples from New Delhi, India. 93 Acquisition of CPE (two OXA-181, one NDM-1) was recently documented in three healthy travelers returning from India without any healthcare contact. 94 Patients with histories of admissions to local hospitals in the preceding three months were also included in the active surveillance. An education pamphlet was delivered to all patients upon admission as a reminder of some important infection control practices ( Figure 5 ). Rectal swabs were collected from patients who fulfilled the aforementioned criteria to identify patients with asymptomatic gastrointestinal carriage of VRE, CRAB and CPE, which are not yet endemic in Hong Kong. Because carriage of MDROs may be unmasked by subsequent prolonged antibiotic use after hospitalization, 95,96 a 'safety net' to screen patients hospitalized for 14 days or more, as well as inpatients with stool sent for Clostridium difficile cytotoxin or culture, was implemented as previously described 90, 97, 98 to enhance detection. For newly diagnosed patients carrying VRE or CPE, bedside assessment is carried out by the infection control team to coordinate and ascertain that strict contact precautions and isolation of these patients in single rooms are implemented. Extensive contact tracing for secondary cases is performed when an index VRE or CPE patient has been hospitalized for more than 48 h in an open cubicle. The duration of extensive contact tracing includes the entire duration of hospitalization of the index patient, covering all potentially exposed patients. Immediate rectal swab screening is conducted for all potentially exposed patients who are still hospitalized within the same hospital. Discharged but exposed patients are labeled as 'VRE or CPE contact patients' in the hospital computer system by infection control nurses, and screening for VRE or CPE are performed upon hospital readmission. For exposed patients discharged to residential care homes for the elderly, site visits and collection of rectal swabs are performed by community geriatric assessment teams within one week. If a secondary VRE-or CRE-positive case is confirmed in a residential care home for the elderly, all residents in that residential care home for the elderly will be screened for asymptomatic gastrointestinal carriage of VRE or CPE. In f