Yesterday I attended a meeting at the Wellcome headquarters in the middle of London. I deliberately exposed myself to several risks: by car from home to Schiphol, by plane to London City and by public transport to the meeting. Each transition harbors a quantifiable risk of ending up in a hospital (accidents, assaults, cardiac events) where there is a quantifiable risk of developing HAI, and I am especially afraid of CPE.
In my own country that risk (CPE HAI) is close to 0, but today I was leaving the CPE-green zone, entering uncommon (future non-European) grounds. If anything happened I would end up in the NHS (No Hope for Survival, someone told me, long ago). As part of my personal risk assessment I read this surveillance manuscript, now ahead of print in JAC, above the North Sea. Based on structured strain and data collection from 21 sentinal UK laboratories they collected (between November 2013 and April 2014) 32 (!) CPE isolates from “clinically relevant cultures”; 14 KPC, 5 NDM, 12 OXA-48 and 1 VIM. The prevalence of CPE among E.coli/K. pneumoniae was 0,02% and the estimated incidence of CPE HAI was 0,007 per 1,000 patient days. Actually, in London there is 1 CPE HAI per 100,000 patient days. The risk in Dutch hospitals can never be much lower.
And it is even getting better on the island. In a moment of “meeting attention deficit” I read my co-bloggers’ contribution on the promise of the UK government to reduce the incidence of Gram-negative BSI with 50%. As most of these infections are from endogenous origine, he seemed to struggle with the “how”. I agree with Jon that most Gram-negative BSI’s originate from endogenous origine, but apparantly he is not familiar with the intervention that may actually satisfy his employer: Selective Digestive Decontamination.
So, I was in the building were Jim O’Neill calculated that within decades 10 Million people will die from AMR each year, where I realized that – considering the risk of CPE HAI – London is as safe as any part of the Netherlands. Keep on doing good and informative surveillance studies and next time I may extend my duration of risk exposure.
Reflections on Infection Prevention and Control 
Great debut post thanks Marc. I think the prevalence of CPE in London is patchy. I published a study earlier this year that suggested a very low rate of carriage on admission (4/~4500 admissions). But then again, other studies have suggested a higher prevalence.
As for selective digestive decontamination, well, I have some choice views (expressed here). I have no doubt that it would reduce GNBSI and generally improve the situation in the short term. But I have really worries about the medium and long-term impact!
LikeLike
Thank you Prof Bonten. What do you think about the paradox of SDD regimen including Colistin and the emerging of mcr-1 everywhere?
Are NEJM results in 2009 still up to date?
LikeLike
Good question. The mcr-1 creates a phenotype with MICs for colistin in the range of 4-16mg/L. Chromosomal mutations lead to much higher MICs, up to >256 mg/L. The effects of topical colistin on mcr-1 carrying bacteria are yet unknown; it could provide selection pressure or could be bactericidal if the intestinal/oral concentrations exceed the MICs (as some believe). In our experience SDD and SOD appeared both not to be selective for sporadic Enterobacteriaceae with MICs >256 mg/L (PMID: 25880968 & PMID: 23203301), but others reported clonal transmission of such strains (see PMID: 23629703), the latter actually is a hygiene problem.
We are currently running a international study on SDD and SOD in different European countries with considerable higher resistance levels than Dutch ICUs. Results expected, summer 2017 (8000 patients), and this will provide more information on this.
Are the NEJM results from 2009 still up to date? They were derived in settings with low-level endemicity of ESBL, absence of VRE/MRSA/CRE/mcr-1. That’s still the case in many ICUs (at least in the Netherlands), and so far I’ve not seen any other intervention being more effective….. So I guess the answer to that question is yes.
Do I recommend SDD in other settings: NO (I eagerly await the results from studies).
LikeLike