Fluoroquinolone use and C. difficile infections: The English miracle not yet explained?

A few weeks ago in LID this marvellous paper, clearly demonstrated the reduction of fluoroquinolone-resistant but not fluoroquinolone-susceptible C. diff infections (CDI) in English hospitals, coined as “the English C. diff miracle”. The CDI decline coincided with the reduction of fluoroquinolone use, but also with a period in which “horizontal” infection control measures, such as hand hygiene, were improved. As the latter would be equally effective in preventing transmission of resistant and susceptible strains, the fluoroquinolone reduction was considered causative for the observed reduction. A very simple model tells us that that is not necessarily the case. 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

SSI – It’s not what you do, but the way that you do it?

20140801-135-see-rock_festival_2014-rick_parfittAnother of my favourite guitarists succumbed to sepsis following surgery just before Xmas, with the sad passing of Rick Parfitt following shoulder surgery, spookily the day after his band Status quo performed their final electric gig (which I was at). The other was Rory Gallagher, who died a few years ago now of MRSA.  Surgical procedures are normally carried out under what should be the most controllable of conditions, yet there are variations in practice, a paucity of quality studies on even the most basic of interventions (such as pre-op bathing) and even when there is good evidence, it is ignored. However I do also wonder if we have been missing something. A paper that suggests no difference between Chlorhexidine (CHG) and Povidone Iodine (PI) for pre-surgical skin prep (both aqueous) recently piqued my interest. It was an RCT (non-blinded) undertaken in clean-contaminated upper gastrointestinal or hepatobiliary–pancreatic open surgery, however that wasn’t the aspect that I became interested in. 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.

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.

Continue reading

PPE for preventing highly infectious diseases

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The use of PPE and the protection of HCWs against highly infectious diseases was (and is) a topic of major importance, around the globe. The recent Cochrane review by Verbeek et al. was probably hoping to offer this “vital” information.

Unfortunately, they found no studies on the effects of goggles, face shields, long-sleeved gloves or taping on the risk of contamination. All they found was very low quality evidence, with high risk of bias and uncertain estimates of effect, that:

  • More breathable types of PPE offer more comfort without increasing the risk of contamination
  • Double gloving and CDC doffing guidance appear to decrease the risk of contamination, and
  • Active more than passive training in PPE use may reduce PPE and doffing errors.

Their conclusions are obvious: we need high-quality studies of the materials, their use and protective effects, safe ways of doffing, and the most adequate training to achieve safe use of PPE for HCWs in the presence of highly infectious diseases or those (even less infectious) that may cause severe harm to HCWs.

But what to do until than? My personal opinion is that we should only use PPE, we are used to and know how to use. First-time users, even if supplied with the best available products, will inevitably fail to remove the PPE without error. Consequently, institutions should have a stable selection of PPE, and in the case of preventing highly infectious diseases, a selected group of HCWs with continuous active training, as it is too late to start when the next epidemic is hitting our healthcare centers.

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