Six weeks ago I blogged on the exposure of Dutch clinical microbiologists by Marcel Levi, former boss of the Academic Medical Center in Amsterdam and now leading 5 academic centers in London. Apart from describing his new “totally resistance-free” work situation, he criticized the microbiologists in both countries for “not attempting to change the money-wasting and empty-brain practice of microbiological diagnostics”. Unfortunately, Marcel Levi is not just “another person” with an opinion. So, here are four suggestions to change his opinion, before all microbiologists have been sacked.
Marcel, I trust you have enjoyed Tuscany as much as I did this summer. To make a fresh start after the summer break:
Following the footsteps of intensivists, clinical microbiologists were instrumental to deliver the evidence that selective digestive (or only oropharyngeal) decontamination is a cost-saving infection prevention measure in ICUs, at least in settings with “Dutch” levels of antibiotic resistance. So, Marcel, since resistance in London was even lower than that, the next thing to do is to make SDD mandatory in your ICUs. Even more can be gained by replacing the expensive component amphotericin B by nystatin. In the meantime, clinical microbiologists could make SDD even more cost-saving by demonstrating that the frequency of surveillance cultures can be safely reduced.
Clinical microbiologists demonstrated that peri-operative decontamination of nasal S. aureus carriage is a highly cost-effective way of preventing post-operative surgical site infections, see. Marcel, has this already been implemented in London? If not, consider to skip the expensive and complex part of detecting S. aureus nasal carriage before surgery. Just treat all with mupirocin nasal ointment and chlorhexidine bathing. It will reduce many money-wasting tests and will actually increase effectiveness (you won’t miss a single patient!), see. The only risk is selection of S. aureus isolates being highly resistant to mupirocin. Yet, with good infection control as in your place it is probably safe to just monitor mupirocin susceptibility in clinical S. aureus isolates, see.
Immediately stop the money-wasting practice of universal screening for MRSA. Or at least stop testing with expensive real-time PCR methods. With adequate hygiene measures in place, as you described, the risk of nosocomial transmission is low. A strategy of screening high-risk patients on admission (clinical microbiologist will know the risk factors) and using very cheap chromogenic culture media will be good enough and save a lot, see.
Just some ideas to help you change your mind. You also mentioned “the truck loads of useless fecal cultures from everyone who dares to produce a droplet of diarhea”. Stop it (the testing, I mean), and you will have even more weeks without Clostridium difficile (which made you so proud).
To others, feel free to cherry-pick from this.