The Trojan Horse

Trojan_horse_ÇanakkaleI’ve been mulling over the issue of sinks in clinical areas a lot recently and a paper published today in the Journal of Hospital Infection has really crystallised my thoughts. Sinks are everywhere; often extra ones are installed in the quest for high hand hygiene compliance however are we really thinking about the risks that these may cause apart from the traditional ones posed by Pseudomonas and Legionella? Do we even really reflect upon what they are used for? Continue reading

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The prevention paradox: E. coli versus Klebsiella

The prevention paradox, as described in 1981, is the “seemingly contradictory situation where the majority of cases of a disease come from a population at low or moderate risk of that disease, and only a minority of cases come from the high risk population (of the same disease). This is because the number of people at high risk is small”, see. In our world this reflects the question how to prevent transmission of ESBL-producing E. coli (ESBL-EC) or K. pneumoniae (ESBL-KP), or both. A new study may help to decide. Continue reading

Making MRSA carriage a crime?

A new chapter has been added to our successful MRSA Search and Destroy policy. Yesterday, a healthcare professional, providing homecare to elderly, testified on Dutch television (item starts @ 12.30 minutes) how unnoticed MRSA carriage had influenced her and her family’s life. It is very laudable that she was willing to share her experience, but it was kind of spooky that she felt that she could only do this if unrecognizable, as if the underworld was still after her and her family. Apparently, MRSA carriage has become a criminal or shameful thing. Continue reading

Water, water everywhere (or nowhere?)

Karakum-Desert-Turkmenistan.-Author-David-Staney.-Licensed-under-the-Creative-Commons-AttributionA new paper by Hopman and colleagues (Andreas is also another author but is being modest) has evaluated the effect of removing sinks from the ICU. The trigger for this intervention was an outbreak caused by an ESBL-Enterobacter that could be related to contaminated sinks. The study looked at what happens if you remove all water sources from the ICU, and all water-related activities were migrated to a tap water-free solution. Continue reading

How much S. aureus is hospital acquired? Mk II

I posted a blog a couple of years ago (was it really that long!) on a fascinating study suggesting that only 1/5 of S. aureus in hospital patients is hospital-acquired. My key conclusion from that study was that the number of potential sources for S. aureus that the team investigated was inadequate to draw any firm conclusions (they didn’t include staff, surfaces, or visitors). I concluded that ‘the next frontier of transmission mapping must be a more comprehensive evaluation of other potential sources…’. The authors must have been reading, because this study from the same group was published recently in Lancet ID, which is a more comprehensive evaluation of other potential sources.

Continue reading

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

(no More) fear of flying*

Last Friday Jarne van Hattem presented findings on ESBL carriage in Dutch travelers returning from ESBL-rich countries at our NCOH meeting and the next day the results appeared in Lancet ID. A great study; quantifying things we already thought, extending our knowledge on risk factors and providing new information on the public health aspects of these imported bacteria. They concluded that acquistion and spread are “substantial and worrisome”. Too bad: all the quantified knowledge lost in 2 meaningless words.

In short, they studied 2001 travelers (ESBL carriage before travel 6.1%) and 34.3% of the non-carriers acquired ESBL during travel; especially in southern Asia (75.1%). Risk fators for acquisition: persisting diarrhea, ciprofloxacin use and eating street food. The median duration of carriage after return was 30 days and 11.3% was still colonized ater 1 year. This implies that returning travelers (depending on region) must be considered at risk for ESBL-carriage (no matter whether they have additonal risk factors) during a certain period of time. Yet, median duration of carriage is short and after 1 year that risk is fairly close to the ESBL-prevalence in the Dutch population.

Is this carriage a health risk for travelers? With >500,000 Dutch travelers to ESBL high-endemicity regions per year, many will acquire (according to what we can detect) ESBL, but how many will develop infections caused by these ESBL-producing bugs? That now is a burning question.

Is this import of ESBL a risk for the Dutch public, that we intend to protect against infections caused by AMR? They also investigated the occurrence of within-household transmission of these bacteria in 215 non-travelling household members and quantified rates with a Markov model. The figure that got most attention was the “12% probability of transmitting ESBL-E to another household member”. Yet, much more informative is the actual transmission rate from which one can derive the effective R0. This rate was 0,0013/carriage day and the calculated effective R0 was around 0.2 (Martin Bootsma personal communication), which might include some overestimation due to false-positive transmission events (no molecular typing). An R0 of 0.2  seems not enough to cause continued transmission – leading to endemicity – coming from these sources, especially since transmission to the next ring (to non-household members) will be less effective. Simply said: returning travelers their household members seem to be – in the Netherlands – dead-end roads for ESBL-producing bacteria. That could be expressed as reassuring.

*Title stolen from Gary Brooker