Update on 2019_nCoV, part 5

All quiet at the 2019_nCoV outbreak front, today (so far), it seems. As the world is now informed about the R_0 concept, we can start thinking how to best provide medical care to patients. The evidence base is empty and needs to be filled, preferably with unbiased estimates from randomized studies. Yet, if we had to define research questions now, and then start looking for partners and then draft a protocol, find funding and wait for IRB approval, the first patient-in might coincide with the last patient affected by the virus. So, for pandemic research you better be PREPARED.

The Platform for European Preparedness Against (Re-)emerging Epidemics (PREPARE) is an ”EU funded network for harmonized large-scale clinical research studies on infectious diseases (IDs), prepared to rapidly respond to any severe ID outbreak, providing real-time evidence for clinical management of patients and for informing public health responses.” The trick for better preparedness is to have ongoing large-scale studies in many different EU regions, that can capture a pandemic whenever it starts.

For this we started almost 6 years ago with what is now called “A Randomized, Embedded, Multifactorial, Adaptive Platform trial for Community-Acquired Pneumonia (REMAP-CAP).” This is a perpetual European adaptive RCT evaluating the effectiveness of several interventions (antibiotics, corticosteroids) in improving outcome in adults admitted to ICU with severe CAP, see and here.

The study design allows addition of study domains, such as for instance diagnostic testing or new treatments, embedded in the existing study protocol. Only a “simple” amendment is required as IRBs already approved the possibility of such adaptations, in case of a pandemic.

REMAP-CAP is enrolling patients in 52 centres in 13 countries in Europe, Australia/New Zeeland and North-America and more ICUs are ready to start. The study team is discussing – on a daily basis – what interventions to add. Corticosteroids and macrolide use for immunomodulation are already included.

Any studies in China? Yes, 2 protocols posted. “A randomized, open-label, blank-controlled trial for the efficacy and safety of lopinavir-ritonavir and interferon-alpha 2b in hospitalization patients with novel coronavirus infection”, see. The comparator is standard care and the target is 160 patients. The other is “a prospective comparative study for Xue-Bi-Jing injection in the treatment of pneumonia cause by novel coronavirus infection”, see. Xue-Bi-Jing is Chinese herbal medication, which will be compared to standard of care, and here the target is 200 patients per study arm. Rumor has it that recruitment has already been completed.

Any news on R_0 today? Not much. A new publication was embraced as good news, as it showed a dramatic reduction of R_0 in time. Indeed, it started with 8 on December 29th and then rapidly declined to a steady 2.5-3 from Januari 2nd till 18th……2019_nCoV.

A hand hygiene cracker from the Christmas BMJ

The annual Christmas BMJ is always good for a laugh. This year, one of the featured articles introduces the idea of using the tune of Frère Jacques to help memorise the WHO’s six-step hand hygiene technique.

And here’s the song in action:

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Persistence and transmission of Candida auris on and from gloves

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Interesting results from Jabeen et al. that many of us might have missed, as they are published in a mycology journal and not in an infection control journal.  Persistence of Candida spp. on latex and nitrile gloves was highest for C. auris and C. parapsilosis.  Interestingly, persistence on nitril gloves was generally less than on latex gloves. Transmission of Candida spp. from gloves (latex, nitril not tested)  to urinary catheter surface was most effective for C. auris and C. albicans.

To be frank, the chosen methods and set-up of the experiments leave quite some room for improvement, but the basic idea of the experiment and the message it conveys are – while not new – of importance: Glove use can be an important factor in the spread of all microorganisms, and in this case, especially C. auris.

Previously it has been shown that glove-use may negatively effect hand hygiene behavior. After years of focusing our attention on hand hygiene compliance and hand-rub technique, this publication is an important reminder, to not forget about adequate glove-use.

Jabeen K, Mal PB, Tharwani A,Hashmi M, Farooqi J. Persistence of Candida auris on latex and nitrile gloves with transmission to sterile urinary catheters.  Medical Mycology, 2019, 0, 1–5 doi: 10.1093/mmy/myz033 Advance Access Publication Date: 0 2019

Are we over-complicating effective hand hygiene technique?

The WHO method for hand hygiene is very well embedded as the ‘gold standard’ for hand hygiene technique. But is it feasible to perform every time in the busy clinical environment? A new study in Clinical Infectious Diseases seems to suggest that a shorter, simpler hand hygiene method be just as effective and more feasible in the real world.

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Working while sick

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Compared with the general population, healthcare workers (HCWs) have an increased risk of being exposed to respiratory pathogens including flu, causing a potential threat for their own health and their patients’ safety.  At present, the problem of HCW vaccination seems to get the main attention when dealing with influenza prevention, whereas the problem of HCWswho work while feeling sick, seems to be far less addressed.  That is, until recently when Chow et al. studied hospital-acquired respiratory viral infections, sick leave policy, and a need for culture change.

The ISAC Infection Control Study group had already piloted a survey on the topic and wishes to poll your thoughts with the present survey.

While there is nothing to earn, except of the good feeling of having helped someone, we kindly ask you to take the questionnaire (takes 4-5 minutes) and send it to others, including friends or family not in healthcare, as we are especially interested in possible differences.

Link for the survey: https://www.surveymonkey.com/r/ISAC_Influenza

Thanks for helping and of course results will be back on this blog.

Must we screen for resistant bacteria?

This is a cry for help. In 2 weeks time I have a pro-con debate on the statement “screening for highly-resistant microorganisms is a must”. I face 2 problems: the organizers gave me the “PRO” position and my opponent is professor Andreas Voss.

We will be watched by a Dutch audience, so the bacteria involved are MRSA, VRE, anything resistant to carbapenems and ESBL-producing Gram-negatives, and I (and hopefully Andreas too) interpreted the question as “screening at the time of hospital admission”.

I am desperately seeking high-level scientific evidence supporting my allocated point. 

My question to the knowledgeable reflectionsipc readership is: What do you consider the single most convincing piece of evidence underpinning my case.

As in all good practice I will provide feedback (if I survive the battle).

Mapping C. dfficile hospital acquisition: short-stay diagnostic areas are important!

Recent genomic studies have concluded that hospital-acquired acquisition of C. difficile is rare, suggesting that acquisition of C. difficile outside of hospitals followed by hospital-onset disease is the most common explanation for C. difficile infection. These studies hinge on an assumption that in-hospital patient contact occurs due to shared or recent stay on the same hospital ward. A short publication in JAMA Internal Medicine eloquently challenges this assumption, suggesting that hospital contact that we would usually assume to be casual and not a risk for acquisition of hospital pathogens (e.g. short-stay diagnostic areas such as ultrasound and endoscopy) can be an important source of acquisition.

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