The war against CPE

An interesting publication on the control of CPE last week. Not in Nature, Science of Journal of Hospital Infection, but in the “Staatsblad van het Koninkrijk der Nederlanden”. The paper, “Besluit van 26 april 2019, houdende aanpassing van het Besluit publieke gezondheid vanwege een meldingsplicht voor Carbapenemaseproducerende Enterobacteriaceae”, with King Willem-Alexander as first author, implies that on April 26th it was decided that from July 1st 2019 on, by law, all CPE detected in the Netherlands must be notified, see. A next step in our war against CPE.

An important, and controversial, measure. Sometimes I’m invited to lecture on the success of our country in maintaining low levels of antibiotic resistance. Contrary to my hosts’ expectations I then say that I don’t think it has anything to do with restrictive antibiotic use in hospitals or excellent adherence to hand hygiene. Yet, there are other – I think much more important – measures, such as maintaining a certain staffing level (which means that beds are closed when the number of nurses declines), having (reasonably) clean and relatively new hospitals with many single-bed rooms and low antibiotic selective pressure among humans in the population. Our GPs are different, in that they prescribe less antibiotics than most of their foreign colleagues.

The other important difference is that we are a small country, with about 70 hospitals and even less microbiology labs. In small communities people tend to look at each other, and we Dutch are not different. Guidelines for controlling MRSA were implemented more than 20 years ago, and no hospital can hide. An outbreak would be detected soon through patient transfer (and local media) and all your beloved micro colleagues would know….. Same holds for the opposite: If you show tremendous power in controlling MRSA, for instance by closing a ward for new admissions because of a single patient with MRSA, others will see that too (and some will admire you for that).

So, this sociological-induced control worked for MRSA, and then for VRE and even for ESBL. But then came CPE. And although we all realized that these bugs are a much bigger threat for our patients than all the previous ones, sharing patient information and isolates became less natural. Detection of CPE was (and still is) a rare event, but in anticipation of a possible future with more CPE our minister of Health initiated 10 regional Care networks to be better prepared for that future, actually to prevent it from happening: In EARRS terms; we want to keep the Netherlands CPE green.

Optimal notification of CPE carriage, including epidemiological data from carriers and sending the isolate for WGS analysis to a central lab (RIVM) was deemed necessary and because of this law this can be done without violation of – otherwise – obstructive privacy rules. Although not everyone was happy with this law (also in the manuscript), the King (or the minister of Health) has decided. The war on CPE has now really started.

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