Does chlorhexidine mouthwash kill patients?

You may think so, with this title: “Oral mucositis as a pathway for fatal outcome among critically ill patients exposed to chlorhexidine (CHX)”, with the conclusion that the “data points to oral mucositis as the main pathway for the association between CHX exposure and enhanced in-hospital mortality.” The research letter is a post hoc analysis of a randomized clinical trial. Time to stop using CHX mouthwash? Or time to stop building strong stories on weak data? Continue reading

On the origin of multidrug-resistant Gram-negative bacteria (MDR-GNB)

The colour of the global crisis of antibiotic resistance is red (if te Gram stain is your reference). In rich countries we have ESBL-producing Enterobacterales (mainly E. coli), but the real problem are carbapenemase-producing strains (Klebsiella, Pseudomonas and Acinetobacter) that are already endemic in lower and middle-income countries. The unanswered question is “where did these resistant bacteria come from”? Animals or bathrooms? Continue reading

Intra-operative vancomycin: to randomize or not

Today we discussed a recent paper published by our orthopedic surgeons on using powdered vancomycin in the wounds of spinal surgery to prevent surgical site infections (SSI). Two years ago I already had a post on the topic. The powder is spread deep in the wounds, on the bone and metal, before fascia and skin are closed. Yet, none of the 3 guidelines addressing prevention of surgical site infections that appeared recently recommends this intervention; WHO (2016) didn’t even include the intervention, CDC (2017) said “don’t do it”, and NICE (2019) acknowledged that the procedure is widely used without strong supporting evidence and recommended: stop doing it and do a trial. Continue reading

An empty gut before surgery?

We Dutch, we love gut decontamination. Not only in critically ill patients, but also in those undergoing elective colorectal  surgery. A decontaminated gut is a safe gut, and that feeling was based on data from Dutch studies. A new study from Finland, published in Lancet, now questions whether our gut feeling was correct. Continue reading

The winner takes it all  for S. aureus

As usual, some of the most interesting presentations at ECCMID were in the late-breakers “clinical trials” session. Four of 5 presentations were on treatment or prevention of S. aureus infection, the other one on oral treatment in patients with refractory fungal disease. With all respect to fungi, the meat was in the aureus, with nothing less than a Shakespearian tragedy. Continue reading

“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. Continue reading

No jab, no play; no jab, no pay

It may be the annual “cucumber time” or Trump-fatigue, but childhood vaccination is dominating Dutch news. The problem: the proportion of children being immunized against, for instance measles, is (slowly) declining and approaches the level that offers herd protection. That is a risk for children in the time window between passive protection by mothers’ IgG and active immunisation (at 14 months) and for persons that cannot be immunized for medical reasons. We were familiar with parents refusing immunization of their kids for religious reasons (because someone forgot to mention vaccination in the bible), but now non-religious and well-educated parents do the same. These “philosophic refusals” mostly decide to do so on information derived from internet. How can epidemiology help us to curb this problem? Continue reading

The antipathy against SDD explained

With the first paper on Selective Digestive Decontamination in ICU patients published in 1983, this year marks the 35th anniversary of one the fiercest controversies in intensive care medicine, infection prevention and clinical microbiology. To celebrate this, Intensive Care Medicine published 3 editorials called the “Antipathy against SDD is justified”: 1 arguing Pro, 1 Con and 1 wasn’t sure. If the contents of these editorials had been patients, a (good) physician would have called them “diagnostic”. SDD is where clinical epidemiology becomes psychology and sociology. Continue reading

Attacking the fecal veneer (part 2)

Last year (Jan 17, 2017) I blogged on an excellent pragmatic cluster-randomized crossover study in which 4 patient room cleaning strategies were tested for their effectiveness to reduce acquisition of bacterial carriage for the incoming patients. The authors’ conclusion was that “enhanced terminal room disinfection decreases the risk of pathogen acquisition”, which I interpreted as “Not for C. diff, may be for MRSA and yes for VRE.” Now the same group published the effects of these interventions on infection/colonization with these pathogens in ALL patients admitted to the hospital during the study period, see. Authors’ conclusion this time: “Enhanced terminal room disinfection with UV in a targeted subset of high-risk rooms led to a decrease in hospital-wide incidence of C difficile and VRE.” Really? Continue reading

The reality of AMR in Greece

This week I attend the general assembly of COMBACTE, this year in Athens. COMBACTE stands for COMBatting AntibiotiC resistance in Europe ( and is part of the New Drugs for Bad Bugs (ND4BB) program of the Innovative Medicines Initiative. Our local host is professor George Daikos, who opened the meeting with an overview of the epidemiology of antibiotic resistance in his country. Continue reading