If you read this, you may well be concerned about antibiotic resistance and consider reducing the burden of disease caused by AMR as one of your professional goals. Broad attention helps us to fight the problem: it creates awareness and funds for research. So, how do we cope with data that may jeopardize these ambitions (raising awareness fort he problem AMR)? Here is the eaxmple of mcr-1. Continue reading
Author: marcbonten
ESBL on meat: be aware of filet Americain
Tabloids have repeatedly warned the people for superbugs on chicken meat, after researchers had convincingly shown that the chicken filets that we buy are contaminated with ESBL-producing bacteria, mainly E. coli. Widely considered a public health threat, it was a decisive argument to insist on reductions in antibiotic use in the agricultural industry in the Netherlands. Yet, whether meat contamination constitutes a risk for human health is unknown. This was now quantified, with surprising results. Continue reading
Attacking the fecal veneer*
What an excellent start of 2017. A great study from the USA today in Lancet: In a pragmatic cluster-randomized crossover study they tested 4 patient room cleaning strategies on the effectiveness to reduce acquisition with relevant bacteria for the incoming patients. The conclusion states that “enhanced terminal room disinfection decreases the risk of pathogen acquisition.” Yet, this paper is so “data-dense” that you must read the methods (and supplements) to get the picture. In one shot: Not for C. diff, may be for MRSA and yes for VRE. Continue reading
Good in 2017: preprint publishing
My blog on the “disease called peer review” (Dec 12th) evoked many comments (including from some journal editors), and these directed me to the concept of preprint publishing. Physicists started this 25 years ago, and were followed by mathematicians, computer scientists, and more recently by biologists. It is not yet widely known or practiced in the medical sciences. At least I was barely familiar with it, but I can only admit that this may well help to cure the “disease called peer review“ and H-indexitis. Continue reading
The day after the WIP died
Yesterday, Andreas Voss heartbreakingly described the end of the Workinggroup Infection Prevention (WIP) in the Netherlands. Yet, the end of the WIP is not the end of the Netherlands. The WIP enormously contributed to the success of Dutch infection control and then ran towards it’s own grave, where many now cry (some like a crocodile).
In the final moments before death, nobody was willing to rescue the patient. What went wrong? The government didn’t want to pay for infection prevention guidelines, as they may feared they would then need to pay for all guideline. More fascinating is that the beneficiaries of succesfull infection control, hospitals, didn’t want to pay either. Either they take infection control for granted or were no longer pleased with these guidelines.
Now, let’s look at the crime scene. The WIP created 136 guidelines! You name it, we have a guideline for it. Haircutters in the hospital? Hospital beds? We have it. All these guidelines were drafted by professionals with the best intentions, mostly for free and in absence of convincing scientific evidence for specific recommendations. No problem, as long as we can use them as “best practices” or recent updates for practitioners.
But the world changed. For every unexpected event in the healthcare system someone is to be blamed, for instance the Health Inspectorate, as they should reassure good care. So, they think: “I don’t wanna be blamed. How can we control that system? Wait a minute, they have guidelines and we just check whether they adhere to their own guidelines”. An understandable point of view.
So, we (as healthcare professionals) are now confronted with “sometimes-not-so-usefull-guidelines” to which we should adhere. As long as we can tick the box of adherence we’re safe. For instance, achieving adherence to the guideline of airway management in ORs has resulted in enormous financial investments for hospitals, without any evidence that it increased patient safety.
The death of the WIP can be used to break this chain. Let’s go back to a few multidisciplinary guidelines on things we really agree on: WIP2.0. Maintaining these guidelines will not be expensive (and can easily be covered by a professional society). And where evidence is lacking, professionals rely on their knowledge and experience, share on best practices and talk to each other when in doubt or need of support.
A disease called “peer review”
One of our newpapers addressed the peer review practice in science. Based on a flawed but sexy paper in Nature, where review obviously failed, the system was diagnosed as sick, and cure is needed. Here is my solution. Continue reading
The art of predicting “broad brush estimates” of people dying from AMR
Sometimes you read something you wished you had authored. For me, that is the essay “Will 10 Million People Die a Year due to Antimicrobial Resistance by 2050?” published yesterday in PLoS Medicine. At last, a scientific response to the highly praised AMR review from Jim O’Neill. Summarized in a few words: scrutinized to the bone, hardly anything remains. Continue reading
Antibiotic Awareness in the Netherlands
Tomorrow is the European Antibiotic Awareness Day: one of these days in that the Dutch feel proud…., when the rest of (most of) Europe recognizes and acknowledges that the Netherlands do a fantastic job in controlling antibiotic resistance. How? Difficult to say, and may be the “diagnosis” should be established by exclusion. Here are at least 3 reasons that did NOT contribute to our success (although many think otherwise)….. Continue reading
WHO guideline on SSI prevention: more clear than feasible?
The WHO guideline for SSI prevention was launched as if it were the iPhone8. I immediately went looking for what I think is the intervention with the strongest evidence: pre-op nasal mupirocine and CHX bathing, see why here. After an interesting read I’m pleased that the guideline is clear, but I missed an evaluation on feasibility and the evidence for simplification is turned around.
Science in transition, or not?
Something is happening in my university. My dean, prof. Frank Miedema (H-index >70), and friends discovered that the blibliometric way of evaluating quality of science (of a person or an institute) is wrong. (Especially) Young researchers are pursuing – for the wrong reasons – a high H-index (many papers cited frequently) and the publication pressure distracts them from doing the better things for patients and society. So, they decided to break free, and they tell their story this week in Nature (high impact factor, isn’t that what they call irony?).
I whole-heartedly agree with the philosophy of “Science in transition”. The impact system is sick, see. In Nature, also the story of Mark Ferguson, former dean of biology at the University of Manchester: as a predecessor of the Science Transitioners he decided 20 years ago that professor applicants should, instead of their impressive publication list, submit what they considered their 3 most important publications, with motivation.
That made me think. What would I submit? Here they are:
The recognition that the number of other patients with VRE in a ward is the best predictor for new acquisitions, see. Bob Weinstein named it colonization pressure, and the subsequent recognition that this number in the ward is influenced not only by acquisitions, but also by admitted and discharged patients got me on a plane to Oxford to learn about mathematical modelling and that the dynamics of AMR in a hospital are quite similar to malaria (healthcare workers being mosquitos). Today, I still enjoy working with mathematicians.
Two years later we had the first 2 outbreaks with VRE in the Netherlands. We studied these isolates, together with a bunch of isolates I took home from Chicago and other outbreaks across the globe. Rob Willems and Janetta Top discovered that all outbreak isolates contained the esp-gene (and others did not), see. Now we know that a subclade of E. faecium, containing esp and much more, is responsible fort he global pandemic of ampicillin-resistant and vancomycin-resistant E. faecium. Today, I still enjoy working with molecular biologists.
Six years ago we thought of ways to bypass the hurdles that killed clinically relevant research for treating community-acquired pneumonia (CAP); antibiotics before randomization to study antibiotics and enrolling only a fraction of those actually treated for CAP. Inspired by a previous study we used a cluster randomized approach and changed the hospital antibiotic policy every 4 months, see. The 3 options were – without preference – recommended by our national guideline. It took us 3 years to get funding and IRB approval, but in the end we were among the first to integrate randomized comparative effectiveness research with patient care, see. I firmly believe that this type of research is the future for infection prevention.
Not sure if I would have been hired, since all 3 studies were published in respectable journals (and were cited). My point, science must transit, but it should not stop us from publishing our work in journals that are read by many colleagues, as I am convinced that these studies would not have received the same attention if published in non-peer-reviewed journals. I trust my dean & Science in Transition are with me on this.
I wrote this blog while listening to my playlist on Spotify, and at the end of writing Carly Simon sang “You’re so vain”.
Reflections on Infection Prevention and Control 