Reflections from Infection Prevention 2018

A lovely few days in Glasgow for the IPS conference. Here’s a few reflections…

Can we halve GNBSI?

In the annual IPS debate, Dr Tim Boswell argued that whilst we can perhaps reduce GNBSI a bit, halving GNBSI is simply not going to happen. The parallel that is often drawn with MRSA (“we halved MRSA BSI, surely we can halve GNBSI”) only goes so far: transmission routes, epidemiology, and interventions are very different. In particular, endogenous infections with a community source are the most common driver of E. coli BSI. Interventions aimed at reducing cross-transmission in hospitals won’t help to prevent these cases. Tim cited a recent study from his group, which concluded that only 8/40 E. coli BSI cases were ‘preventable’ (albeit accepting that there are no agreed definitions or consensus of what we mean by ‘preventable’). Tim highlighted the curious north-south divide in England in the rate of E. coli BSIs in England, probably rooted in health inequality as evidence that E. coli BSI (and GNBSI in general) is a public health issue that can’t be fixed with hospital-focussed interventions (which we are already maxed out on anyway!).

Prof Jacqui Reilly argued that we can halve GNBSI because we have evidence-based interventions, (some!) experts believe it’s possible, targets work in driving improvement, some small success has been made already, and we can achieve the systems leadership required to drive a reduction across the whole health economy. There is some evidence that declines in antibiotic use in the community will reduce selective pressure, reverse AMR, and make therapy of healthcare-associated conditions that could result in GNBSI more effective. Also, a couple of studies (here and here) suggest that the rate of E. coli BSI culture positivity remained constant but the number of patients sampled increased due to improved awareness of sepsis. This suggests that the national increase in E. coli BSI is driven by improved ascertainment rather than a genuine increase.

The audience at IPS sided with Tim in concluding that we can’t halve GNBS (about 60:40). I recently had a debate on this blog with Martin Kiernan on the same theme, and the result was the same then too (70:30). Having heard the latest evidence, I still conclude that we can halve GNBSI. There’s much to go for in our quest to halve GNBSI: improve hydration, improve treatment of bacterial infection especially in the community (before it becomes a BSI), and reduce unnecessary urinary catheterisation (which is most of it).

Getting social

Brett Mitchell gave a talk about social media (especially Twitter) for healthcare professionals – during which the results of our blogoff were unveiled. I’m devastated to tell you that Brett’s pitch for the best paper of 2018 won the vote (approx. 60:40), so Brett’s choice (on contact precautions) was considered to be the best of 2018 so far (rather than my choice on drains and CPE). I’m not taking this result too well…

Anyway, Brett’s talk was ok (I suppose), covering the value of social media for healthcare professionals. Some interesting themes around traditional vs. social media, and real vs. fake news (and how to tell the difference). The most interesting part of Brett’s talk for me was the new research and outreach possibilities presented to us by social media. We’re already beginning to see some research around the use of social media related to IPC popping up (e.g. the anatomy of a good IPC/AMR blog, and drivers for social media ‘success’ in IPC). There’s also much to learn from how social media is affecting other medical / scientific sectors (e.g. those exposed to negative comments about HPV were more likely to express negative views; it seems that negativity is infectious on Twitter).

Why are we ignoring HAP?

Martin Kiernan gave an important talk on HAP. Hospital-acquired pneumonia is one of the most common HCAIs, and a high-quality study found that HAP has the highest burden of any HCAI. And yet HAP is curiously understudied: there’s not even enough evidence to make any evidence-based recommendations! Martin conjured a HAP prevention bundle from a very sketchy evidence base: mobilisation, bed positioning, oral care, hand hygiene, managed dysphagia, aspiration prevention, and managed viral infections (useful review here). Why did Martin have to go to specialist nursing journals rather than infection prevention and control journals (or higher impact general medical journals) to find evidence around HAP prevention? Perhaps we don’t believe that HAP is real? That’s certainly true in some cases: “HAP” is diagnosed to unlock antibiotics “just in case”. But that in itself should be an important topic to study and unpick. We need to stop ignoring HAP!

Towards water-free patient care

One of the talks that got me thinking the most was by fellow Reflections blogger Andreas Voss, on the risks associated with water. There’s an excellent review on healthcare outbreaks associated with water sources here. A few key studies:

  • We know from genomic studies that the patient and room microbiome including water (aka environmentome) overlap.
  • A recent JHI study illustrates the risk of Pseudomonas transmission from water vividly: 30% of taps in the ICU were contaminated with Pseudomonas, and 30% of transmission was found to be related to water by genotyping.
  • Washing your hands in Pseudomonas-contaminated water isn’t a brilliant idea.
  • Sinks and drains are a smoking gun in the transmission of CPE.

So, what’s the solution? Introducing taps with an improved design improved matters considerably in one study. But some have gone even further and implemented a water-free ICU. It’s a radical approach but the evidence from two studies is impressive: a dramatic reduction in water-related Gram-negative pathogens (here and here, with some previous analysis by Andreas on Reflections here). So, how does this work in practice? Sinks are physically removed. Washing is performed using sterile water or wipes. Most hand hygiene is performed using alcohol gel, and hand wipes are used where hand washing would have been performed previously. Certainly food for thought!

And finally…staying healthy in body and mind with Dr Phil Hammond

We had the pleasure of the company of clinician, commentator, and comedian Dr Phil Hammond. I had the daunting task of a live conversation / interview with Dr Phil during the conference (which went ok, I think). We talked about health promotion, health inequality, behaviour change…and brexit. Two key themes for me:

  • Firstly, how vital health promotion in the widest sense is to infection-related outcomes. We know that material / social deprivation is an important contributor to HCAI and AMR. If we don’t address and improve health in general, we will struggle to contain HCAI and AMR. There are simple steps that we can take and promote around the principle of self-care: 70% of our health depends on how we live (more sleep, exercise, less booze etc), 30% depends on getting the right healthcare.
  • Secondly, are we so focussed on taking care of our patients that we forget to take care of our colleagues and ourselves? We rarely talk about mental health – but we need to. A lot more! Here’s some links to some mental health in the workplace resources from NHS Employers and HSE.

I hope that those of you able to make the conference have taken some ideas and energy back to your hospitals. And I hope that those of you unable to make it get a flavour of the conference from this reflection (although I always wish I could clone myself to cover all of the sessions)! A lot of work goes into putting together a conference on this scale – so thanks to all involved for the hours and hours of work that goes on mainly in people’s spare time behind the scenes.

One thought on “Reflections from Infection Prevention 2018

  1. Thanks for the great wrap up of the conference. Its been interesting and provided some opportunity to reflect on where our program needs to focus for 2019.


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