What’s lurking in the hospital environment? The importance of cleaning and disinfection in infection prevention and control

Jon Otter (@jonotter) Environment , , ,

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I was asked to speak to a group of link nurses at Southampton Hospital earlier in the week, and thought I’d share my slides, here.

I am passionate about the importance of surface contamination in transmission: I still think it’s really under-rated. I am pretty sure that most healthcare workers would have no idea that your chances of acquiring C. difficile infection (and others) is influenced by who used the room or bed space before you. And who would believe that VRE could survive on a dry surface for 4 years? Or that touching a surface is as important as touching the patient in terms of acquiring contamination on your hands?

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Tubular Bells

Martin Kiernan (@emrsa15) CAUTI, Infection Prevention and Control , ,
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Picture courtesy of Justin Cellini

Bells have a certain resonance for me. When they toll, people listen as they are normally of significance. I have just heard one. I have been waiting from this paper to come out since I heard the authors speak about progress at last year’s Infection Prevention Society meeting in Glasgow. Decision-making prior to passing a urinary catheter is something close to my heart, since we need to know why people do things if we are to modify practice. For me, telling people that a list of specific indications for an intervention exists merely makes the decision-maker pick which one on the list fits their desire or perceived need to catheterise most.

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ICPIC 2015

Andreas Voss (@AVIPNL) Meetings , ,

all-in-oneSorry, this was the attempt of a mobile upload straight from the meeting. Here a cleaned version, actually including  the picture. I promise, I will not continue (for now) to promote ICPIC via this blog. I do so via Twitter (@avipnl), but someone just presented a nice slide expressing the fact that you want a lot (too much) from one thing – in this case disinfection wipes.
“Wipes are like an egg-laying, milk-giving, wolly pig!”

Just passing through

Martin Kiernan (@emrsa15) Antibiotic resistance, Epidemiology, MDR-GNR , ,
Picture courtesy of Shanna Trim
Picture courtesy of Shanna Trim

Travel is easy, cheap (well, depending on your desire for luxury) and you get to meet some interesting characters on your way. Unfortunately, as this recent study from France just published in Clinical Infectious Diseases shows, some of the species that you interact with may have escaped your attention (unless you’re carrying agar plates or some fancy molecular kit with you).

The authors studied travellers attending five vaccination clinics in France prior to and post-travel looking for acquisition of MDR Enterobacteriaeceae. Over 50% came home with more than they bargained for, smuggling MDROs into France in their colons.

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CRE – too weak to spread!?

Andreas Voss (@AVIPNL) CRE , , ,

superbug

(Photo: thinkprogress.org)

In the May issue of ICHE, Weber et al. published their findings of a study looking at the environmental contamination of rooms occupied  by patients colonized or infected with CRE. In addition to their observations they actively inoculated test surfaces with 102 CRE (which I find rather low). They found that the contamination in the patients’ room was infrequent (8.4%) and at low levels (5.1 CFU/120cm2). With the single exception of K. pneumoniae on formica, alle CRE had a less than 15% survival at 24 hours and a 0% survival after 72 hours.

Should we just conclude that the chance of CRE transmission from the environment is very low?

I believe that this conclusion would be too early and probably wrong. The survival of micro-organisms in the environment is clearly strain dependent and while the authors used clinical isolates they did not mention if they included a strain that has proven its ability to spread (eg. outbreak isolates). In general multi-resistant bacteria may loose some of their fitness – including the ability to survive in the environment – but survival studies like those of Kramer et al. show survival of multiple weeks for E. coli and Klebsiella spp.

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What drives carbapenem resistance? Carbapenem use, stupid!

Jon Otter (@jonotter) CRE , ,

An outstanding study from colleagues at Imperial shows that if you use a bucket-load of meropenem (a carbapenem antibiotic) one year, you see an uptick in carbapenem-resistant Enterobacteriaceae (CRE) the next. The figure below plots meropenem use in the previous year with the incidence rate of OXA-48 producing K. pneumoniae CRE.

mero usage correlation

Figure: The use of meropenem in the previous year plotted against the incidence rate of OXA-48 producing K. pneumoniae

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European approaches to MDR-GNR prevention and control

Jon Otter (@jonotter) MDR-GNR , , , , ,

HISME

I was privileged to be asked to speak at the inaugural Healthcare Infection Society Middle East Summit in Dubai this week on ‘European approaches to MDR-GNR prevention and control’. You can download my slides here.

I began with a (probably too lengthy) preamble outlining some overall points:

  • CRE is a big deal in Europe, especially in the UK, and has prompted unprecedented action on a national level in the form of a Toolkit, a Patient Safety Alert and a letter to all CEOs requesting (demanding?) an action plan. The political picture is similar elsewhere in Europe and in the USA. Although this level of government scrutiny can be challenging, on the whole I think it’s beneficial, and is probably a sizeable factor in the successes achieved with MRSA and CDI.
  • Do we go universal or targeted? There’s been much discussion recently about abandoning traditional targeted (aka vertical) approaches in favour of universal (aka horizontal). Interesting, all guidelines that I could lay my hands on favoured a targeted approach for MDR-GNR, centred around screening and isolation of carriers.
  • Where is the evidence? We are hamstrung by the lack of high quality studies telling us with any certainty what works to control MDR-GNR. Pretty much all studies to date are either performed in an outbreak setting (regression to the mean…) or include multiple interventions (which worked?), or both. The few studies that evaluated a single intervention in an endemic setting are underpowered to deliver a meaningful conclusion. So, we need bigger and better studies!
  • How do you produce good guidelines – who is on the guideline writing dream team, and what are the key pitfalls to avoid. Plus, importantly, how to good guidelines translate through a good policy into good practice?

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EBOLA VIRUS DISEASE – RELATED ACTIVITIES AT ICPIC 2015

Andreas Voss (@AVIPNL) Meetings ,

Schermafbeelding 2015-06-03 om 21.05.15

Sorry, as part of the ICPIC organizers, I can’t stop myself to post this.

At ICPIC 2015, there will be a large number of activities related to Ebola virus disease (EVD). Due to the unique experience of field workers and scientific experts present at ICPIC 2015, and considering the large demand, the organizers and scientific committee members are glad to inform ICPIC participants about the many activities around EVD that will take place during ICPIC 2015.

Ebola virus disease will be addressed:

  • at the pre-ICPIC workshop “Ebola: Hands On” on Tuesday 16 June (10:00 to 16:50) in the presence of more than 30 field experts and faculties. The “Ebola: Hands On” workshop is free for ICPIC participants
  • at the Opening Ceremony
  • during ICPIC at MTE, symposium, poster and poster rounds sessions

We are convinced that ICPIC participants will get the best insight and advice on Ebola virus disease out of these activities.

Ebola Activities At ICPIC

For those interested in Ebola I might add that ARIC just published “Preparedness of institutions around the world for managing patients with Ebola virus disease: an infection control readiness checklist” a first project of the newly establish ISC working group on infection prevention and control.

Dispatches: Pan-drug-resistant doom – are we there yet?

Guest Blogger Antibiotic resistance , , ,

Old_Testament_prophet-1

Guest blogger and Acute Medicine trainee Dr Nicola Fawcett (bio below) writes…As the local Prophet of Antibiotic Resistance Doomsday to our population of hospital physicians, I’m always interested in finding out if the pan-drug-resistant superbug has emerged that is going to wipe us all out, for credibility purposes if nothing else. (Resistance Is Coming! Prepare thyself! Wash thy hands and document thy indication and duration or face Everlasting audits and perpetual personal protective equipment!). For the record – I’m actually a Registrar in Acute and General (Internal) Medicine. I’m doing some time in the world of ID/Micro/Genomics in the hope that it will help me work out whether it’s ok to just hand out co-amoxifrusiclavamide + nebs to everyone if not sure what’s going on. However  this question seems rather inextricably linked to antibiotic resistance, and having spent some time now with people who seem to know what they’re doing,  I’m increasingly flabbergasted at the massive divide between the views of microbiologists who see the latest data, and the views of the common garden hospital physician. Therefore my side-mission, if you like, has become to spread the good, or rather, spectacularly bad news that antimicrobial resistance is currently spreading around our biosphere at a scale and speed at which we simply cannot react fast enough.

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Hot stuff?

Martin Kiernan (@emrsa15) Environment, General, Surgical Site Infection , , , ,

9028655160_a307baac17_zSo I’m really quite interested in seasonality of infections. I first became interested in it when looking at increases in E. coli bacteraemia for ARHAI (report here) because of Jennie Wilson’s excellent paper showing seasonality of gram negative bacteraemia, echoed by similar observations and conjecture on warmer weather, more infection. This is true in hospitals as well as the community. Why would this be? We have tussled with increasing E. coli bacteraemia in the UK for a few years now. Goes up every summer, does not return to the baseline, goes up again next summer etc., etc.. Other countries have also reported this. I have heard some suggest this is due to longer hours of daylight leading to more barbeques and more sexual activity. Given that the majority of infections in the UK are >70 years of age, my senior years have no fears for me then.

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