Year: 2015

Appraising the options for detecting carbapenemase-producing organisms

Jon Otter (@jonotter) CRE , , , ,

CPE agar

Carbapenemase-producing organisms (including CPE) present important clinical challenges: the “triple threat” of high levels of antibiotic resistance, virulence, and potential for rapid spread (locally, regionally, nationally, and globally)! However, these organisms somewhat ironically also present challenges to detection in the clinical laboratory. You’d expect that since these organisms are so important clinically they’d be dead easy to detect in the clinical lab – but this isn’t the case.

A comprehensive review published in Clinical Microbiology Reviews provides an overview of the diagnostic approaches to detect carbapenemase producers in the clinical lab. Figures 6 and 7 of the review provide a useful overview of the two broad approaches you could take: culturing organisms on agar plates, or using nucleic acid amplification techniques (NAAT – most commonly PCR) directly from a rectal swab.

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Cost of CDI – New estimate, but how accurate?

Martin Kiernan (@emrsa15) C. difficile, Finance

bank-17626_640To be honest I’m a bit fed up with quoting the £4000 per CDI case that was calculated by Mark Wilcox and colleagues back in 19 0 plonk (1996 to be exact) and so I was quite excited to stumble across a new estimate from Merseyside whilst browsing ‘Value in Health‘, one of my usual reads. Well, possibly not.. although perhaps it should be – and it does support open access.

Nakamura and colleagues presented an abstract at the 18th International Society for Pharmacoeconomics and Outcomes Research (ISPOR) meeting and have calculated the mean extra cost of a patient with CDI to be £10,956.82, although as the authors point out, how much of this is attributable to the extra cost of CDI rather than the multiple co-morbidities that likely contributed to the infection leading to the antibiotic treatment, which led to the CDI continues to elude us. The authors are continuing to work on this and I await their final findings with interest, however for now I’ll settle for £11,000 per case as opposed to the 1996 figure of £4000 (data collected in 1995) and is probably more realistic than just allowing for inflation that has averaged at 2.8% pa, which would have made it £6868. As we know (well all of us apart from the Treasury), health inflation is way ahead of normal financial indicators.

Influenza among afebrile and vaccinated HCWs

Andreas Voss (@AVIPNL) Influenza , , ,

sneeze 2

Picture: gerardnadal.com

Influenza is considered to contribute to the morbidity and mortality of our patients and during the flu season, some estimate that as many as 1 in 5 patients contract nosocomial influenza; via infected HCWs.

After having had close and personal experience with influenza last season I do have a better understanding for some things.

  1. You don’t want influenza if you can avoid it!
  2. I fully understand while you wish your worst enemies to have an inflammation of their pleura (Dutch saying: “Go and have pleuritis”) – it really, really hurts – A LOT.
  3. Flu vaccination programs for HCWs and guidelines preventing febrile HCWs to work may be a pretty smart idea! Or not?

In a recent study, Ridgway et al. had a look at the validity of “febrile” as an indicator of having influenza. After screening 449 HCWs with respiratory symptoms, they found a total of 41 (9.1%) with proven influenza. Only half of the HCWs actually were febrile, with no significant differences between vaccinated and non-vaccinated HCWs.

Thus, while we should continue to vaccinate our HCWs (in my opinion, not part of the article) and hope for a match of the vaccine with the circulating virus, the practice to only look for influenza in febrile HCWs needs to be reconsidered.

Reference

Ridgway JP, Bartlett AH, Garcia-Houchins S, Cariño S, Enriquez A, Marrs R, Perez C, Shah M, Guenette C, Mosakowski S, Beavis KG, Landon E. Influenza among afebrile and vaccinated healthcare workers. Clin Infect Dis. 2015 Jun 1;60(11):1591-5.

The room lottery: why your hospital room can make you sick

Jon Otter (@jonotter) Environment , , , , ,

lottery

In this era of increasing patient choice, let’s imagine you were offered the choice between two identical looking hospital rooms. Your chances of picking up a multidrug-resistant organism (MDRO) are approximately doubled if you choose the wrong room. But you have no way of knowing which room is safest.

So what explains this lottery? The key information you have not been told is the MDRO status of the previous room occupants. One of the rooms was previously occupied by a patient with C. difficile, and if you choose this room, your risk of developing C. difficile infection doubles. And it’s not just C. difficile – this same association has been demonstrated for MRSA, VRE, Acinetobacter baumannii and Pseudomonas aeruginosa. Underpinning this association is the uncomfortable fact that cleaning and disinfection applied at the time of patient discharge is simply not good enough to protect the incoming patient.

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Norovirus – The organisation’s IPC ‘Canary’

Martin Kiernan (@emrsa15) Isolation, Norovirus, outbreaks , ,

5136479476_0d76640581_bIt’s the most Chunderful time of the year (or maybe not). The Norovirus ‘season’ will still be on us and a few points are well worth reflecting on. A recent systematic review of Norovirus risk in high and middle-income countries asserts that there may be as many as 12.5 million infections annually these countries alone, with possibly as many as 2.2 million outpatient visits related to the illness. Personally I have always liked having a bit of norovirus around. Keeps the staff on their toes and gives a good indicator of how IPC is really being performed rather than another set of 99% compliant hand hygiene audits.

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Why infection prevention and control teams should be on Twitter!

Guest Blogger Infection Prevention and Control , ,

twitter birdie 2

Guest bloggers Fiona Reakes-Wells and Carolyn Dawson write…

“Are you going to twit that?” honorary IPC team member (my mother) asked one day when I took a picture. “Will I be famous?”.

Twitter, tweet, retweet, hashtag, Follow Friday (FF) are commonly used jargon you will find in your friendly “twictionary”, however these days they are also terms you will often hear used in your daily lives.  The small blue Twitter bird symbol is used by the media, advertising companies, universities, and even governmental departments for quick and concise information sharing with the masses.  However under its umbrella term of ‘social media’, Twitter is met with scepticism by some people, a frivolous exercise opening yourselves up to criticism and destroying professionalism.  But is this truly the case?

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Q-fever and lymphoma linked!

Andreas Voss (@AVIPNL) Q-fever , ,

Schermafbeelding 2015-10-08 om 15.04.38

Okay, the following is not strictly infection control, but it has to do with infections and it will have major impact on how people who were unfortunate enough to contract Q-fever will feel about their safety.   The pathway of chronic infections – interaction with IL-10 – immune-supression and cancer isn’t new, but to my knowledge mainly described in viruses. The Netherland had one of the largest outbreaks of Q-fever, leaving behind a sizable number of (chronic) Q-fever patients.  Many of these patients will be shellshocked by the increased chance of developing lymphoma. Consequently, research to cooperate (or dismiss) Raoult’s study is needed, to relief the patient population from uncertainty.

Bacterium that causes Q fever linked to non-Hodgkin lymphoma

AMERICAN SOCIETY OF HEMATOLOGY

(WASHINGTON, October, 13, 2015) -The bacterium that causes Q fever, an infectious disease that humans contract from animals, is associated with an increased risk of lymphoma, according to a study published online today in Blood, the Journal of the American Society of Hematology (ASH).

Q fever is caused by infection with Coxiella burnetii, a bacterium primarily transmitted through the excrement of cattle, sheep, and goats. Approximately 3 percent of healthy adults in the United States and 10-20 percent of those in high-risk occupations such as veterinarians and farmers have antibodies for C. burnetii, suggesting previous infection.1 Symptoms of Q fever vary from person to person and can be acute and resolve spontaneously, or chronic and persistent. Because some patients have been reported to also suffer from lymphoma, researchers believed that this type of cancer could be a risk factor for Q fever. However, the experience of one patient prompted doctors to consider the opposite – that the infection might actually cause the lymphoma.

“During a follow-up scan in a patient we had successfully treated for Q fever, we observed a tumor close to the location of the previous infection,” said senior study author Didier Raoult, MD, PhD, of Aix-Marseille University in Marseille, France. “The discovery that it was a lymphoma tumor containing C. burnetii encouraged us to consider that the infection might have contributed to the development of the cancer.”

In order to better understand the association between C. burnetii and lymphoma, Dr. Raoult and colleagues screened 1,468 patients treated at the French National Referral Center for Q Fever from 2004 to 2014. Investigators conducted imaging of patient tissue samples to identify seven people, including the initial patient, who developed lymphoma after C. burnetiiinfection (6 patients were diagnosed with diffuse large B-cell lymphoma and one with follicular lymphoma). Of all the Q fever patients included in the study, 440 presented a persistent infection concentrated to one area.

To determine if patients with Q fever have a higher risk of lymphoma than the general population, researchers compared the incidence of lymphoma in the Q fever registry to the incidence reported in France’s general population. Based on this analysis, researchers conclude that patients with Q fever are 25 times more likely to develop diffuse large B-cell lymphoma than those without the infection. In addition, the odds of lymphoma in patients with persistent concentrated infections are higher than those with other forms of Q fever.

Upon further imaging of the patient samples, investigators observed that Q fever patients with lymphoma demonstrate overproduction of the critical anti-inflammatory pathway interleukin-10 (IL-10), suggesting that suppression of the immune system may have allowed the lymphoma cells to evade immune detection and multiply.

“As we continue to learn more about the association between C. burnetii and lymphoma, these results should encourage clinicians to survey high-risk patients as early as possible for potential cancer,” said Dr. Raoult. “Ultimately, this early diagnosis and treatment would improve outcomes for Q fever patients who subsequently develop lymphoma, particularly those with B-cell non-Hodgkin lymphoma.”

Guidelines to control multidrug-resistant Gram-negative bacteria: an ‘evidence-free zone’

Jon Otter (@jonotter) MDR-GNR , , , , ,

citation needed

I recently had a review published in CMI comparing EU guidelines for controlling multidrug-resistant Gram-negative bacteria (MDR-GNB). I included the following guidelines in my review: ECCMID 2014, Irish MDRO, PHE CPE, HPS CPE, ECDC systematic review on CPE (not strictly a guideline, but did include some recommendations). A couple of important points arise:

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I’ll take the tube.. out!

Martin Kiernan (@emrsa15) CAUTI , ,

file6971249324663A few papers on the use of urinary catheters have caught my eye recently. It’s a subject close to my heart and was the subject of my eponymous lecture at the Infection Prevention 2013 meeting in London, available online for insomniacs via the excellent Webber Training Teleclass recording The slides are here. Despite these devices being second to peripheral cannulation in the ‘most’ used devices’ awards annually (and a clear winner in the ‘most overused’ section), the evidence base is somewhat thin. Are they inserted well? Possibly (and indeed probably) not. Do they only get inserted appropriately and are they speedily removed? Um… maybe not. Continue reading →

Spread the word, not the MDROs!

Guest Blogger Epidemiology , ,

xdro registry

Guest blogger, Rita Bos (bio below) writes:

This month, while randomly searching Pubmed with the subject MDRO (I know, a rather bizarre hobby), I came across a French study on MDRO information in patient transfer letters. In this paper, which was published in the French journal “Médecine et maladies infectieuses” Lefebvre et al (of the Infection Control Unit of the Dijon University Hospital, Dijon, France) investigated the proportion of transfer letters that contained information of infection or colonization with MDR bacteria.

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