“Why Dutch hospitals are so good at beating superbugs”

It is with great pleasure that I ask your attention for this article that appeared in the Economist. Yes, we still have low resistance rates in our hospitals and if you’re interested in how that happened, read it. The prosaic composition contains two parts; a very realistic thriller-like opening, followed by a second part with a rather unrealistic explanation. Both parts are separated by a short sentence of absolute nonsense. Time for a review.

The first part, no more than about 30 lines, is a very comprehensive review of successful infection prevention, as executed in my country, mentioning no less than 13 infection control measures:

  1. Air pressure differences to keep germs from escaping rooms
  2. Quarantining patients
  3. Surgical gowns when entering rooms
  4. Respiratory masks when entering rooms
  5. Pre-emptive isolation of…
  6. … high risk patients
  7. Testing of healthcare workers
  8. Prudent antibiotic use
  9. Single-bed rooms
  10. Unused beds “wrapped as tightly as sandwiches in plastic foil until being used”
  11. Used beds cleaned in “dishwasher”
  12. Separated elevators for dirty and clean beds
  13. Daily fresh uniforms for staff

To be crystal clear: this is far from complete, not mentioned:

  1. Number of patients in a ward are titrated upon the number of available staff
  2. New patient admissions can be temporarily stopped in case of documented transmission.
  3. The number of infection control staff is based on the number of beds…
  4. Infection control staff is supervised by a clinical microbiologists, ..
  5. .. and recommendations are usually followed.
  6. Hospitals are remarkably clean (at least that is what foreigners say)…
  7. … and the oldest buildings are about thirty years.
  8. You can’t admit a patient without notification of risk factors for AMR in the electronic patient system.

… and this list still is not complete.

Then the story tells that – in the Netherlands – “the prevalence of some superbugs in the general population has almost doubled in the past 5 years“. I really have no idea what superbugs are meant here, may be the doubling of E. coli resistant to amoxicillin-clavulanic acid, that occurred after the change in EUCAST criteria…. Or it may be that the prevalence of CPE has increased from 0% to a few returning travelers from Asia.

After this short intermezzo the Dutch success is explained by: “In the end it is all about hand hygiene”, followed by examples of outbreaks and poor hygiene practices in the “not so fortunate” countries. Not mentioned, though, is that there is no evidence that hand hygiene in the Netherlands is any better than in any other country. And that is not because there is lack of evidence.

But, let’s embrace the first part of the article: Dutch (and Nordic countries) do better! And let’s be clear about the second part: That success is not caused by better hand hygiene. I am not against hand hygiene, but without (at least some of) the other aspects, good hand hygiene may not be sufficient to control spread, and with these measures good hand hygiene may not be instrumental (or some may say, may not be needed). This also questions the relevance of studies quantifying the effects of hand hygiene when studied as a single intervention.  Effective infection control requires a full box of measures, of which individual measures will not be effective on their own.

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