As is now becoming traditional, I thought I’d share a few reflections from the recent IPS conference in Harrogate. Fantastic to see the submitted abstract published, full and free, in a Journal of Infection Prevention supplement.

The ‘swing’ from Gram-positive to Gram-negative threat – Prof Gary French

The focus of IPC in recent decades has been problem pathogens of a purple variety (i.e. Gram-positive bacteria), like MRSA, VRE, and C. difficile. However, there has been a swing towards problematic pink pathogens (i.e. Gram-negative bacteria) in recent years, like Acinetobacter baumannii and the Enterobacteriaceae. The multidrug-resistant Gram-negative bacteria bring with them the spectre of pan-drug resistant infections. Prof French felt that antibiotics introduced eras of complacency in the 1960s-1980s, where the ‘fear of infection’ was lost first by healthcare professionals and then by the public. Healthcare professionals are beginning to re-discover the fear of infection (especially those who have tried to treat a pan-drug resistant infection), but it will take some time for the public to catch up. We need to urgently address the drivers of antimicrobial resistance (like removing unnecessary use of antibiotics in animal husbandry). If we act quickly, and in a co-ordinated way, hope is not lost, as demonstrated by the UK reduction in MRSA bacteraemias.

Improving improvement – Prof Mary Dixon-Woods

Prof Dixon-Woods explained how to improve quality improvement initiatives. The highlight for me was the introduction of an untranslatable German word: ‘Verschlimmbesserung’, which means, effectively making things worse by trying to make things better (if only I knew how to pronounce it)! To avoid Verschlimmbesserung, quality improvement in healthcare should be about thinking fast but acting slow, learning from mistakes (yours and others), sticks and carrots, and the right mixture of individual vs. system thinking and action. An individual cannot improve their performance if the system isn’t right, and a system cannot improve its performance if individuals are not interested in improving themselves!

Antimicrobial stewardship as everybody’s responsibility – Dr Kieran Hand

Dr Hand, an antimicrobial pharmacist, spoke about antimicrobial stewardship as everybody’s responsibility. There’s an easy fallacy to fall into that antimicrobial stewardship is the sole domain of prescribers – but we all have an important role to play (especially nurses who are in many ways the ‘effector arm’ of AMS). It is good to see some progress towards national and international collaboration to drive AMS, with improved transparency via Fingertips, some reductions in anti-infective use in primary care, some positive rhetoric from the Americans, and the TATFAR collaborative. But we need to go further, and fast, in exploring new approaches, such as ‘symptomatic treatment’ of infection to reduce the burden of anti-infective use.

Are contact precautions dead and buried? – A Dr Fidelma Fitzpatrick vs. Dr Eli Perencevich debate

If you are regular reader of the Controversies blog, you’d be forgiven for believing that contact precautions are dead and buried. However, as illustrated by this debate, it’s not quite that simple.

Eli argued that studies evaluating the impact of stopping contact precautions are limited by not evaluating post-discharge infections and lacking the surveillance cultures required to detect cross-transmission that does not manifest in clinical infection, that contact precautions have a behavioural benefit in improving compliance with basic IPC practice such as hand hygiene, that universal contact precautions has a clinical impact in reducing MRSA, and that the harm associated with contact precautions in some studies is over-stated by inadequate experimental controls – and seems to disappear when adequately controlled studies are performed.

Fidelma argued that the conflicting evidence around contact precautions does not support their use. First up, what exactly are contact precautions, and how they should they be applied? How can we have an academic debate about an intervention that is so poorly defined and fundamentally different on either side of the Atlantic given the stark difference in the proportion of single rooms? Although you can criticise the study design, it seems clear that IPC doesn’t disintegrate into rampant transmission if contact precautions are discontinued. Plus, discontinuing contact precautions is a resource saving initiative, which is extremely attractive in the current financial climate. Finally, we wouldn’t need to apply contact precautions at all if we were performing standard precautions properly!

It was a slightly odd set-up in that Fidelma was arguing against contact precautions from a hospital that uses them, and Eli was arguing for contact precautions from a hospital that doesn’t! But I got a sense that the debaters were putting across genuine views, and not talking to a side of the debate they didn’t subscribe to. My conclusion: contact precautions make sense and fulfil the logical idea of ‘disease segregation’. The studies that seem to show stopping them makes no difference are probably explained to a large degree by the fact that they’re not done right in the first place! It was interesting that all agreed that you should apply contact precautions for the ‘really bad bugs’ (like CPE and C. difficile diarrhoea), so what is the logical difference between these and other organisms?

Summary

I was grateful for the opportunity to share my passion for social media amongst healthcare professionals, and lead a CPE workshop, where we found that the groundswell of healthcare professional opinion was at odds with several key national recommendations!

As usual, kudos to IPS and the organising committee, who have done a fantastic job in putting together another thought-provoking conference.