I was privileged to be asked to speak at the inaugural Healthcare Infection Society Middle East Summit in Dubai this week on ‘European approaches to MDR-GNR prevention and control’. You can download my slides here.
I began with a (probably too lengthy) preamble outlining some overall points:
- CRE is a big deal in Europe, especially in the UK, and has prompted unprecedented action on a national level in the form of a Toolkit, a Patient Safety Alert and a letter to all CEOs requesting (demanding?) an action plan. The political picture is similar elsewhere in Europe and in the USA. Although this level of government scrutiny can be challenging, on the whole I think it’s beneficial, and is probably a sizeable factor in the successes achieved with MRSA and CDI.
- Do we go universal or targeted? There’s been much discussion recently about abandoning traditional targeted (aka vertical) approaches in favour of universal (aka horizontal). Interesting, all guidelines that I could lay my hands on favoured a targeted approach for MDR-GNR, centred around screening and isolation of carriers.
- Where is the evidence? We are hamstrung by the lack of high quality studies telling us with any certainty what works to control MDR-GNR. Pretty much all studies to date are either performed in an outbreak setting (regression to the mean…) or include multiple interventions (which worked?), or both. The few studies that evaluated a single intervention in an endemic setting are underpowered to deliver a meaningful conclusion. So, we need bigger and better studies!
- How do you produce good guidelines – who is on the guideline writing dream team, and what are the key pitfalls to avoid. Plus, importantly, how to good guidelines translate through a good policy into good practice?
Preamble concluded, I moved onto the nitty gritty of which interventions we have available, and which we should implement for different organisms and in different settings. Screening, isolation, stewardship, hand hygiene, and cleaning / disinfection are the pillars of infection control – and CRE is no different. But what do we do about the more controversial areas: decolonisation, screening of staff, cohorting staff and patients, environment screening and eduction?
To take ‘decolonisation’ as an example of one area of controversy, carriage of MDR-GNR can and often does continue for months or years, especially with the Enterobacteriaceae. So can we make any attempt to decolonise carriers? Some have tried ‘selective’ digestive decontamination, which doesn’t seem to work particularly well. Faecal microbiota transplantation looks more promising, but it’s early days. For the time being therefore, we’re stuck with once positive, always positive, for CRE at least.
What works to control MDR-GNR? Since we don’t know and are working in something amounting to an evidence vacuum, we need to throw the kitchen sink at the problem (aka an infection control bundle) in the hope that one or more of the elements will do the trick!