Contact Precautions for Endemic MRSA and VRE

dilemmaby Andreas Voss and Eli Perencevich,

intentionally posted on “Reflections” and “Controversies” at the same time as a reaction to the JAMA Viewpoint by Morgan, Wenzel & Bearman

 

During the recent ICPIC 2017 and a pre-meeting think tank, the sense and non-sense of RCTs looking at various infection control measures was a major point of discussion during many sessions. Data from well-designed quasi-experimental studies, epidemiological evidence, and logic seems to vanish, whenever a new RCT is published, even if the results are not applicable to situations that are non-endemic, have higher or lower compliance with the preventive measures in question, or whether the intended measures were actually applied within the intended patient group.  Some studies seem to assume that the transmission during the first days of admission are of no consequence. Others assume that given endemicity and a high patient load, the intended measures such as single-room isolation can’t be applied, even if a patient was randomized to receive those measures.

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WHO IPC Core Components

While I had seen the WHO IPC Core Components, I have totally missed the great video they made.  Thus, with no further comment, here the link to this well-made video.

Just in case that the link via the picture doesn’t work, copy and paste the following link into your browser: https://www.youtube.com/watch?v=LZapz2L6J1Q&feature=youtu.be

C. auris questionnaire – the outcome

Overall 61 colleagues from 17 countries answered the questionnaire.  A large proportion (26 of 61) of the answers came from the UK, which might have to do with the fact that the first European outbreak was described in England.

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Of the respondents 32.8% said that their institution released a warning about C. auris.  Analyzing the data separately for the UK and the other participating countries, it became clear that the first European outbreak had impact on the preparedness. In the UK 42.3% of the institutions were warned about the unique capacities of C. auris, versus 25.7 in all other countries.  Regarding the existence of a written guideline dealing with C. auris, the differences were far less pronounced, namely 26.9% versus 20.0%, respectively.

53.9% of the UK responders believe that their lab can correctly diagnose C. auris, versus 31.4% in the other countries.  In addition, the proportion of responders, who didn’t know if their lab was prepared, was higher outside the UK (45.7% versus 26.9%, respectively).

Despite the emerging spread of  C. auris clusters this questionnaire is an indication that most institutions are not adequately prepared.  Obviously the sample is really small, but the outcome was predictable.  With an increasing body of literature, including papers on diagnostic methods and infection control measures, we should hope that the situation should change very soon.  Thus, don’t lean back, start writing.

 

Candida auris part III. Are you prepared?

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MMWR just published on the ongoing transmission of Candida auris in the US, while at the same time PLOS Pathogens came with an excellent review on the topic.

By now I had the debatable pleasure to be around for the birth of a few “superbugs”, but this one is clearly putting a lot of effort into reaching the top of the list. I believe (classical pessimist) that many institutions still ignore this new adversary (or are even unaware), and most certainly have no game-plan to prevent its introduction and consequent spread.  In the MMWR publication the current recommendations for C. auris–colonized or infected patients were repeated, with only one change from previous recommendations, namely that a more effective (sporicidal) disinfectant is needed, but I seriously wonder who follows this guidance.

Thus, here it comes, another 30-seconds-questionaire.  Why?  Because I hope that you will prove me wrong and that we – the infection control people at the frontline – act on threat, instead of re-act once we are overrun.

Link to questions  https://www.surveymonkey.com/r/QCK9RWS

References

Notes from the Field: Ongoing Transmission of Candida auris in Health Care Facilities — United States, June 2016–May 2017. Weekly / May 19, 2017 / 66(19);514–515 https://www.cdc.gov/mmwr/volumes/66/wr/mm6619a7.htm?s_cid=mm6619a7_e

Chowdhary A, Sharma C, Meis J. Candida auris: A rapidly emerging cause of hospital-acquired multidrug-resistant fungal infections globally. PLOS Pathogens  https://doi.org/10.1371/journal.ppat.1006290 May 18, 2017

The decreasing importance of the Impact Factor

Earlier today, ARIC’s (www.aricjournal.com) publisher (BioMed Central) signed the San Francisco Declaration on Research Assessment (DORA).

Eighteen years ago, when the start of open access changed the world of scientific publishing and distribution of research, the “new” open access journals continued to rely on a “quality measure” of their journals that is in place since 1975; the Impact Factor (IF). A measure based on the number of citations over the number of citable articles.

Many academic institutions judge(d) the academic merit of their researchers by IF points gathered, rather than the quality of their work. Consequently, researchers select a journal for their submission by the IF.  Still, as BMC stated in todays announcement: “over-reliance on the IF has never felt right to us. No one metric should be the be-all-and-end-all”.  Therefore, many journals including ARIC, include Altmetrics on their articles, based on downloads, Twitter, blog posts and other (social) media use. By the way, Preeti Malani explained Altimetrics nicely in the meet-the-expert session at ECCMID we gave together.  Other metric scores are presently implemented by Elsevier.

BMC wants to go further by signing the San Francisco Declaration on Research Assessment  and thereby pledging to “greatly reduce emphasis on the journal Impact Factor as a promotional tool by presenting the metric in the context of a variety of journal-based metrics”.  For all those still relying on IF scores for their academic career, don’t worry, BMC will not entirely cease promoting the IF, but look forward to see more and new metric scores.

 

Can we halve Gram-negative BSIs by 50% by 2021? The crowd say “No”

Most of those casting their vote supported Martin’s (somewhat pessimistic) view that we can’t halve Gram-negative BSI by 2021 (see the figure, below).  Let me first give you my own, unspoiled opinion (written before the results of this survey were known).  I was intending to vote for option 3 (the English can’t, the Dutch might) but I am not even sure of that; actually, I believe that neither the English nor the Dutch can.

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The day the WIP died

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Today it became official that the Dutch Workingparty on Infection Prevention (WIP) will no longer be supported by funds from the Dutch Ministry of Health. Therefore, after 30-years of coordinated, voluntary work by infection control nurses, infectious diseases specialists, and clinical microbiologists (supported and strengthened by various, topic-specific healthcare professions) the number one IPC guideline organization found a sudden and in-part unexpected death.  I am proud to have been part of the WIP, which was rightfully seen as one of the beacons of IPC, admired by many countries who had none or by far not as well organized guideline organization.  The WIP was fundamental to the success of Infection Control in the Netherlands and even if some say that it wasn’t the only contributing factor, all those doing Infection Control know that the present state of AMR and HAI control could not have been achieved without the WIP. Was all the WIP produced “gold”? Certainly not. Despite best intentions some recent guidelines went over the top, but overall the set of guidelines produced by the WIP are of high quality and an enormous treasure, that might now be lost for the future.

Rumor has it that Dutch Public Health Services, the Professional Society for Elderly Care Specialists (Verenso) and other professional medical societies will take it on them to issue infection control guidelines (in part for their own specialty).  If that is truly the case, why stop at killing coordinated and independent Infection Control guidelines, why not take over Infection Control at whole, starting with surveillance.  I can ensure (by the lessons of the past) that HAI rate will immediately drop by up to 50%.  The Dutch have a nice saying about situations that are wrong by default and don’t leave you with a lot of trust or hope: “The butcher who checks the quality and safety of his own meat”.

I believe that only an independent, integrated and coordinated approach (= by one organizational structure) can ensure the basics of effective and sound infection control.  If the Dutch Ministry of Health and the medical professional societies are serious about their engagement to control AMR and HAI, in my opinion, a future solution can only be the formation of a WIP 2.0.

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Disclaimer.  The opinion in this post is a personal  and does not reflect the opinion of the national professional boards I am a member of.