It is great to see the long-awaited ‘Benefits of Terminal Room Disinfection’ (BETR-D) randomised controlled trial of a UVC automated room decon (ARD) system published, in the Lancet, no less! This study firms up the importance of environmental contamination in transmission, and demonstrates additional benefit of UVC over and above enhanced conventional methods for VRE, maybe for MRSA, but not for C. difficile.
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
The end of antibiotics
A case of pan-drug resistant NDM-producing K. pneumoniae CPE that resulted in a fatal infection in a US woman has prompted a lot of coverage and discussion on both sides of the Atlantic. Although this report is concerning, not least because the patient succumbed to the infection, this is hardly a new scenario. There are parts of the world where pan-drug resistant CPE are commonplace and have been for years (for example parts of India, the likely country of origin of the organism in this case). Before getting to the case report in detail, let’s take a moment to review this case series from India, published in 2014. 13 patients with pan-drug resistant Gram-negative bacteria (7 of whom were infected with K. pneumoniae, 4 of these 7 died) were reported in a specialist cancer treatment centre over 18 months over 2012/13. This evidence, from half a decade ago, shows that pan-drug resistant CPE is by no means a new phenomenon! Continue reading
The silent Mycobacterium chimaera epidemic
There has been much discussion about the risk of Mycobacterium chimaera infections associated with contaminated heater-cooler units (HCUs) used in cardiothoracic surgery. A study published recently in CID explores the risk in the UK, and provides further evidence to link these tricky-to-treat infections to contaminated HCUs.
WHO is setting your IPC agenda
The World Health Organisation has updated its 2009 Guidelines on Core Components of Infection Prevention and Control Programmes. The report highlights eight ‘core components’ for IPC:
SSI – It’s not what you do, but the way that you do it?
Another 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
“Santa isn’t coming to town”
WARNING: This isn’t a heart-warming Christmas tale. It’s actually rather sad.
In Christmas BMJ classic, a team of US researchers have explored associations with Sanda Claus not visiting paediatric wards over Christmas 2015. Whilst I am pleased to report that Santa made an appearance on 90% of the wards overall, heart-wrenchingly, Santa was least likely to visit paediatric wards in the most deprived areas.
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.
The day the WIP died
Today it became official that the Dutch Workingparty on Infection Prevention (WIP) will no longer be supported by funds from the Dutch Ministry of Health. Therefore, after 30-years of coordinated, voluntary work by infection control nurses, infectious diseases specialists, and clinical microbiologists (supported and strengthened by various, topic-specific healthcare professions) the number one IPC guideline organization found a sudden and in-part unexpected death. I am proud to have been part of the WIP, which was rightfully seen as one of the beacons of IPC, admired by many countries who had none or by far not as well organized guideline organization. The WIP was fundamental to the success of Infection Control in the Netherlands and even if some say that it wasn’t the only contributing factor, all those doing Infection Control know that the present state of AMR and HAI control could not have been achieved without the WIP. Was all the WIP produced “gold”? Certainly not. Despite best intentions some recent guidelines went over the top, but overall the set of guidelines produced by the WIP are of high quality and an enormous treasure, that might now be lost for the future.
Rumor has it that Dutch Public Health Services, the Professional Society for Elderly Care Specialists (Verenso) and other professional medical societies will take it on them to issue infection control guidelines (in part for their own specialty). If that is truly the case, why stop at killing coordinated and independent Infection Control guidelines, why not take over Infection Control at whole, starting with surveillance. I can ensure (by the lessons of the past) that HAI rate will immediately drop by up to 50%. The Dutch have a nice saying about situations that are wrong by default and don’t leave you with a lot of trust or hope: “The butcher who checks the quality and safety of his own meat”.
I believe that only an independent, integrated and coordinated approach (= by one organizational structure) can ensure the basics of effective and sound infection control. If the Dutch Ministry of Health and the medical professional societies are serious about their engagement to control AMR and HAI, in my opinion, a future solution can only be the formation of a WIP 2.0.
Reflections on Infection Prevention and Control 