I attended a thought-provoking session at the recent Healthcare Infection Society (HIS) conference in Liverpool on reducing GNBSI (you can download some of the speaker abstracts here). It seems that the hefty majority of E. coli BSIs are rooted in issues outwith the walls of acute hospitals. So the question is, who’s going to tackle these issues to prevent GNBSI? Who’s going to go for GNBSI (sorry, couldn’t resist another pop-culture reference to the ‘80s – who could forget ‘Going for Gold’ with Henry Kelly).
Russell Hope from PHE gave an overview of the epidemiology of GNBSI in the UK from the mandatory reporting system:
- Understanding the sources and risk factors for coli BSI is the first step to reducing them (and more widely GNBSI).
- The urinary tract is the most common source (although we have performed research to show that the relative contribution of the urinary tract will vary from setting to setting compared with other sources).
- The latest ESPAUR report shows that, reassuringly, the rate of resistance to key antibiotics remains constant in GNBSI. However, the burden of resistant bacteria is rising because the number of GNBSI cases is increasing.
- Not all GNBSI are the same, with risk factors for Klebsiella BSIs more hospital-related than for coli BSIs. This means we’ll need a slightly (or perhaps radically) different set of interventions to prevent Klebsiella vs. E. coli BSIs.
- There’s a sharp regional difference in the rate of coli BSIs in England, with E. coli BSIs much more common in Northern England. Why is this? Although it’s not clear, it seems likely that this is driven by socioeconomic factors.
Mark Wilcox began by asking whether we can achieve the ambition to halve healthcare-associated GNBSI by 2021. My own view is yes – but it will be very difficult – and won’t be achievable everywhere; although I’m aware that not everybody agrees with me!
- The increase in coli BSI isn’t unique to England/UK; there’s evidence of corresponding increases in France and Switzerland.
- Increases in coli BSI and UTI in Oxfordshire are associated predominantly with increases in the community. Meanwhile, nosocomial E. coli UTI actually seem to be falling (in this region at least)!
- The seasonal peaks in coli BSI are clear – with more cases in the warmer summer months. But why is this? Temperature and dehydration in the elderly seems most likely.
Jennie Wilson challenged us to think practically about what can be done to reduce GNBSI.
- coli BSI is about 10x more common than MRSA at the peak of its powers.
- We need to intervene across the healthcare economy (not just acute care) to effect a meaningful reduction on coli BSIs.
- Jennie used the Pareto principle (aka the 80:20 rule) to zoom in on most important coli BSI prevention measures: strengthening community IPC, improving diagnostics and treatment in older people in the community, and focussing on preventing UTI in >70s (specifically by improving hydration).
- Given that dehydration is a clear risk factor for coli BSI, hydration is a simple, low cost intervention. And yet, depressingly, funding to support hydration in the frail elderly is decreasing as the number of frail elderly is increasing!
- Where to start in addressing urinary catherisation in the community? An unpublished IPS study shows a community urinary catheter prevalence of 11% (range 2-22%). Worryingly, only 50% had an active management plan (and a roadmap to removal). And only 13% had catheter passport.
- The HOUDINI study shows that asking simple questions about urinary catheters reduces catheter prevalence (from 23% to 18% – moderate but significant findings).
The session was interesting and useful to focus our minds on the first steps to reducing GNBSI. There’s clearly a sizable portion of GNBSIs (and especially E. coli BSIs) that are rooted in dehydration / urinary catheterisation in the elderly in the community. This all seems like low-hanging prevention fruit. But who’s going to actually do this prevention work? Acute IPC teams are running at full capacity just about keeping on top of issues within acute hospitals. Community IPC teams are covering huge amount of ground outside of acute hospitals, both geographically and metaphorically. Without additional investment, or a seismic realignment of priorities (and reallocation of resource), it’s difficult to see who’s going to go for GNBSI.