Year: 2016

Reflections from IFIC 2016

Jon Otter (@jonotter) Conferences

ific

I enjoyed my first IFIC experience over the past few days in Vienna, and thought I’d share some reflections.

I found the pro-con debate between Dr Michaal Borg and Prof Gary French on whether we need more evidence to improve infection prevention and control useful. (Clearly, my vote was for Prof French, my PhD supervisor and all-around acadmic mentor.) Prof French gave a good case for an evidence-based medicine approach to IPC, bemoaning poor-quality evidence to support IPC interventions and an over-reliance on ritual and tradition. Although decent IPC study designs are tricky (and tricker than for an antibiotic trials), they are possible, as illustrated by the small number of cluster RCTs we have at our disposal. Dr Borg argued convincingly that, even if cluster RCTs support on intervention, they would likely be performed in high-resource, academic teaching hospitals, which are a different plant to the average hospital so may well not be applicable. Furthermore, clinicans are pretty poor at following guidelines even if they are evidence-based because culture eats policy for breakfast! Michael questioned whether the ‘English MRSA Miracle’ was founded in evidence-based medicine, or a pragmatic multi-faceted intervention. On balance, the room sided with Michael, agreeing that we have enough evidence to make a big different (but all agreed that better quality evidence wouldn’t hurt)!

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What are we doing to improve hospital room cleaning and disinfection?

Jon Otter (@jonotter) Contamination, Disinfection , , , , , , ,

I gave a webinar last week for 3M (you can download my slides here) on “Your hospital room can make you sick: How improved cleaning and disinfection can help”. I asked the audience what they were doing to improve cleaning and disinfection, and thought I would share the findings. I don’t know the exact size of the audience (but it’s usually a couple of hundred mainly US based IPC folks), and the audience were allowed to choose any answers that applied to them for the second two questions.

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Why are we not using existing data for healthcare-associated infection surveillance?

Guest Blogger Surgical Site Infection , ,

ssi

This is a guest post by Dr Gabriel Birgand (bio below), a researcher at Imperial College London…

Surveillance is an essential component in any infection control programme. In UK, the surveillance of infections associated with some procedures (e.g. certain orthopaedic procedures) is mandated by Public Health England. This surveillance requires time and represents either a full time job (i.e. dedicated nurses doing the data collection and follow-up of patients undergoing surgery) or additional work (i.e. surveillance of catheter-associated urinary tract infection by infection control nurses). This process is time-consuming, expensive and dependent on the rigour of the person in charge of the surveillance. Despite proven value, the involved nature of the method makes these manual HCAI surveillance systems difficult cumbersome to deliver. Moreover, hospitals often struggle to recruit and retain nursing staff dedicated to surveillance meaning that reporting is frequently incorporated into other posts, which interrupts other clinical duties and may reduce the detail of reporting.

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We need to EMBRACE engineers in the fight against HCAI and AMR

Jon Otter (@jonotter) Antibiotic resistance , , , , , ,

Embrace logo ok

I attended the first EMBRACE seminar today at Imperial College London. EMBRACE (Engineering, Medicine, Natural Sciences and Physical Sciences Bridging Research in Antimicrobial resistance: Collaboration and Exchange) is a gap-bridging collaborative aiming to bring together Engineers, Scientists, Doctors, and others to find new ways to address AMR and tackle HCAI. I thought I’d share some of my highlights from the seminar.

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Probable Person-to-Person Transmission of Legionella

Andreas Voss (@AVIPNL) Legionella , ,

Schermafbeelding 2016-03-04 om 00.40.08

Ana M. Correia and colleagues (N Engl J Med 374;5 February 4, 2016) present a convincing case of person-to-person transmission of Legionnaires’ disease between son and mother. Seen the epidemiology of the two cases and the results of whole-genome sequencing, the only part of the short report I do not understand is the “probable” in the title. I wouldn’t know what else to include in order to call it “proven”.

Consequently, the question is whether this “new” transmission route has implication for infection control in the hospital setting. The mother had very close contact over an extended amount of hours with her severely coughing son, in a small and badly ventilated room. In opposite to HCWs who in this situation generally would wear a mask, she obviously used no personal protective equipment. Finally, while described as formerly healthy, no further details are given about the conditions possibly increasing the susceptibility of the 74-year old to Legionella.

Thus, while person-of-person transmission seems proven in the present case, I believe that the circumstances are unique and don’t require to change the present infection control measures taken in patients with Legionnaires disease.

Everything is in place.. so that’s alright then

Martin Kiernan (@emrsa15) Decolonisation, Surgical Site Infection , ,

8465992771_213dabc72c_zI am always interested in compliance. What makes staff implement an intervention reliably? What makes a patient follow the advice they’ve been given? A new retrospective cohort study purports to look at what factors influence compliance with preoperative regimes aimed at preventing surgical site infection (SSI). The authors were of the opinion that socio-economic group would be a major factor in whether individuals would be compliant with measures that are likely to reduce the risk of SSI, since this has been demonstrated to be the case in chronic health issues such as asthma. Disappointingly the authors stated that the method of determining at adherence is described elsewhere with the accompanying reference to an 4-minute abstract given at a paediatric orthopaedic conference in Toronto in 2013 which, if you weren’t there, you’ve missed it. However they do provide a small amount of detail and of the 2-5 protocol tasks they only mention bathing and decolonisation of those screened.

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Are spores the secret of the success of FMT in treating recurrent CDI?

Jon Otter (@jonotter) C. difficile , , , ,

Characteristic of the aimes strain of b anthracis is the smooth

I have been following the literature around the use of faecal microbiota transplantation (FMT) for the treatment of recurrent Clostridium difficile infection (CDI). FMT is spectacularly effective but rather crude – and may have some associated risks, not least the possibility of transmissing infectious organisms we have not yet discovered! There is also the issue of administration. Compared with recurrent CDI, a duodenal infusion (aka tube up the backside) isn’t so bad – but an oral delivery would be preferable. The ‘crapsule’ (oral FMT) has been tested and is effective, but it requires a large number of crapsules to reach the required dose. So, the search is on to distill the effective elements of FMT into a format that can be delivered more easily. Some work has been done on exploring various combinations of live bacteria – with variable success.

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Review on AMR: progress to date

Jon Otter (@jonotter) Antibiotic resistance , , , ,

amr review

Like many others, I am keeping a close eye on the UK Government’s commissioned ‘Review on AMR’. The Review team have been tremendously productive over the last few years, already releasing detailed reports on:

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Colistin resistance in CPE: an emerging threat

Jon Otter (@jonotter) Antibiotic resistance , , ,

colistin structure

I am becoming increasingly interested in colistin resistance in CPE, not least because of this work that we will be presenting on colistin resistance in CPE at ECCMID in a few months time. I have been brushing up on how colistin resistance occurs in CPE, and why it is important, so thought I’d share my findings. I started with a pubmed search for “colistin resistance mechanism” on 12/02/16 and this is what I found (85 hits from the initial search):

Colisin

Colistin is an old class (discovered during WWII) of cationic antibiotic. Colistin (polymyxin E) is a polypeptide bactericidal agent and is one of the two clinically available forms of polymyxin agents (polymyxin B and polymyxin E). Colistin interacts with lipopolysaccharide in the outer membrane, resulting in a leaky and ultimately dead bacterial cell.1 Issues with presumed nephrotoxicity have kept colistin very much on the top shelf, but the emergence of CPE has brought colistin down a shelf or two – and we are learning that the nephrotoxicity tradionally associated with colisin may not be so bad afterall.1

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Antibiotic surgical prophylaxis: stewardship’s ‘elephant in the room’?

Jon Otter (@jonotter) Antibiotic resistance , ,

Doxycycline_100mg_capsules

We are all pretty comfortable with the idea that we have used too many antibiotics in the past and now we are reaping the consequences. I think we are also all in agreement that we need to start using antibiotics much more rationally – and keep the big guns firmly on the top shelf, double-wrapped in password-protected packaging that you can only access with a fingerprint and retinal scan (whilst acknowledging that they will still somehow be prescribed by a junior doctor at 3am for a sniffle). But I get the feeling that we all have a bit of a blind spot (or soft spot) for surgical prophylaxis. Here, the situation is different, surely, because the consequence of an SSI is so great that the likely ‘cost’ of widespread surgical prophylaxis is outweighed by the gain of fewer SSIs? But has this become stewardship’s elephant in the room? We are comfortable talking about restricting carbapenem use in acute hospitals, but I don’t hear as much discussion about stopping the use of antibiotics for surgical prophylaxis! On one level, isn’t this is the same arguments as for ‘selective’ digestive or oral decontamination (SDD / SOD) in the ICU? Here, the argument in factor of SDD / SOD is compelling: fewer deaths and less spread of resistant bacteria. But indiscriminate use of antibiotics, which is bound to fuel antibiotic resistance in the long run, just cannot be a good idea, particularly in the high-risk ICU population.

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