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
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.
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”.
Here we are again, the year flew by and it’s time for Antibiotic Awareness Day/Week. This time around, I will spend my time in a call-center, answering questions of concerned citizens/ex-patients in Germany. Smart idea of a friend in the German public health service and probably smarter than doing what we usually do: organize a meeting, ask all our colleagues to come, and preach to our own community.
While I believe that there is no ID or Clin Micro person left that is not convinced of the importance of saving our miracle drugs (Australian campaign), I know that I will get questions I can’t answer, or at least, don’t know if my answers are truly true.
Here it goes, my antibiotic conundrum that could be classified as “Antibiotic Myth”:
Is it true that I have to finish my antibiotic treatment as prescribed?
Will “too short” lead to antimicrobial resistance, or is it the “too long”? My guess, 99% of the professionals will answer this question by releasing an avalanche of questions, regarding the bug, the host and the site of infection, but I have to insist on a simple “yes” or “no”. Sorry, but those are the rules of the “30-Second-Questionnaire” and you can’t argue the rules.
Thus here is my request. Follow the link to the questionnaire, take 30 seconds to answer the question (and 4 others) and email, twitter, blog or use any kind of communication you can think of to forward it to your friends and family. I promise, I will post the outcome right here, a week or two later.
Sometimes waiting for research highlighting an issue that you know is a problem is like waiting for a bus.. Following on from my colleague @jonotter who last week posted about MRSA spread in nursing home settings, I was interested to read this new paper from the USA, published in the Journal of the American Geriatric Society. The study notes the high prevalence of Multi-Drug Resistant Organism (MDRO) carriage in nursing homes that was in excess of that in hospital settings and sought to determine any associations. The findings are interesting, if not surprising.
So I’m really quite interested in seasonality of infections. I first became interested in it when looking at increases in E. coli bacteraemia for ARHAI (report here) because of Jennie Wilson’s excellent paper showing seasonality of gram negative bacteraemia, echoed by similar observations and conjecture on warmer weather, more infection. This is true in hospitals as well as the community. Why would this be? We have tussled with increasing E. coli bacteraemia in the UK for a few years now. Goes up every summer, does not return to the baseline, goes up again next summer etc., etc.. Other countries have also reported this. I have heard some suggest this is due to longer hours of daylight leading to more barbeques and more sexual activity. Given that the majority of infections in the UK are >70 years of age, my senior years have no fears for me then.
Not so long ago, we (that is Andreas Voss, Martin Kiernan and Jon Otter) put our heads together and started talking along the lines of “a team is greater than the sum of its parts”…and the “Reflections” blog was conceived.
We are all keen bloggers with hopefully complimentary interests and expertise so we hope that you will enjoy our new blog.
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Well, I’m two days in to my first ECCMID meeting, and what can I say, it’s huge. There also seems to be a bit of IPC creeping in, however one thing has struck me. There has been debate as to whether some interventions, for example chlorhexidine washing, is effective but in reality it seems to be common with many interventions in IPC that the real issue isn’t the intervention, it is getting people to reliably implement it that is the real issue.It is the same for pre-op prophylaxis, warming etc., etc., etc. We give feedback on SSI rates to surgeons, but what about the others who have an influence on the bundle that should be implemented. Not seen anyone look at performance of individual anaesthetists or other theatre practitioners in implementing antibiotic prophylaxis, warming, supplemented O2 and glucose control yet they are the gatekeepers of these interventions.
Whether something works in a lab or is theoretically possible seems to me to be a bit academic if no-one will do it. I saw a study today presented by Stephan Harbarth, who was defending screening and decolonisation (I prefer suppression) for Staph infection prevention and the compliance was <50% although there seemed to be an effect. Andreas Voss countered that if we cannot implement an intervention we should not be putting it in place, a fair point. In my humble opinion we really need to undertake some good qualitative studies that look at why interventions that may be (and sometimes that absolutely are) effective are not implemented despite the evidence. Is it that we are unable to personalise the outcome (for staff) or that (in the case of patients) that the perception of risk to the self is low, despite the evidence, as in smoking and alcohol intake. Perhaps we should have to describe how to implement reliably as part of the research and development process for the intervention. Otherwise are we just producing yet another publication or free paper that will not reliably and consistently be implemented and that will never really see the light of day?
Two new interesting papers in ICHE, both of significance I think. The first from Kings’ College Guy’s and St Thomas’ in London examines the degree of environmental contamination from patients with diarrhoea and toxigenic C. difficile but undetectable toxin. These patients are called a “potential Clostridium difficile excretor” in some papers. In this study, Biswas and colleagues (including Jon Otter and Simon Goldenberg) demonstrated that C. difficile was recovered from 49% of rooms from patients producing toxin and from 34% of the rooms of “potential Clostridium difficile excretor” group. Call me ‘Mr Picky’ but at what level of contamination does ‘potential’ become actual? 13% of sites tested in the ‘potential’ group were positive (around half that of the CDI group). So, actual infection seems to cause more contamination, which if patients are having more bowel movements I would accept, but the level of contamination from those without toxin production is, I would say significant (not forgetting that the toxin test is as reliable as flipping a coin). The authors are right, all excretors are a risk and we should not shrink from efforts to detect them. Thinking further, It would be interesting to see if the level of contamination could be linked with the frequency of bowel movements (and possibly the Bristol stool chart score?). Should be possible if nursing records are reliable (ahem..). Without getting too graphic there would likely be a splatter factor. Should we increase cleaning frequency for patients with multiple type 7 stools in a day?
The second paper looked at the association between hospital room square footage and acquisition of CDI, showing an Odds Ratio of 3 for every increase of 50 square feet. Interesting, possibly effective cleaning is more difficult in a large space, the cleaning equipment is recontaminating or any disinfectant is losing efficacy? What are the implications for multi-occupancy bays as in the UK? Still lots to learn about the environment.
Pretty worrying editorial in Clinical Infectious Diseases this month, discussing the issue of Polymixin resistance in Acinetobacter. So basically no treatment options and an attributable mortality of 30% from an organism that isn’t normally that virulent. Although these organisms do not seem to be causing too many problems in the UK, it is a different story in Asia. New therapeutics are some way off and there have been a few false dawns. So how about a real concerted effort to prevent infections and transmission in the first place. A good honest look at infection rates, realistic audit and feedback of hand hygiene compliance (instead of the non-credible >100% usually trumpeted), the same for assessing the effectiveness of cleaning, instead of the rose tinted spectacles that are the usual method. Infection prevention and control activity isn’t a PR activity; until new options for treatment come to fruition it may be all that we have.