There have been a few important updates on the prevention and control of MDR-GNR from ECCMID, here in Madrid. I thought I’d share a couple of key reflections.
The 13th International Federation of Infection Control (IFIC) meeting took place in Buenos Aires, Argentina in October 2013. A colleague who attended sent me some notes from the meeting, which I was not able to attend. I found the notes useful, so thought I’d share them (albeit a little late)!
The first was on government regulations in infection control. The Pro delivered by H Baguio from Uruguay and Con by M Borg from Malta. H Baguio gave examples where government regulations have had impact on infection rates, citing the case of MRSA in the UK and reductions in bacteraemia, UTI and KPC prevalence after governmental regulation and auditing introduced in Uruguay. M Borg gave examples were governmental interventions did not improve the situation: for example, a 5x increase in the cost of medical waste disposal due to an insistence on considering it hazardous, when much could be considered non-hazardous. Also, there is a suggestion that since CLABSIs became non-refundable by the US government, many hospitals have started using peripheral lines over central lines to avoid financial loss. Another possible consequence is a less active attempt to detect infections in US hospitals, and a reticence to admit high-risk patients to avoid infection. However, in general the debate was not really pro-con as both admitted that some sort of government regulation is needed but they were not the only solution. This was reflected in the final results: 50% pro and 50% con.
The second debate was about universal vs. targeted MRSA screening. T. Boswell was arguing for universal screening, while E Lingaas of Norway was for targeted. There were good arguments from both sides but the vote suggested a swing towards targeted screening. I think the debate would have been more interesting if it as about universal screening for all pathogens of interests such as the emerging MDR Gram-negative bacteria. Whether you choose universal or targeted screening will depend on your country and healthcare setting. In countries with high carriage prevalence, universal screening will be more beneficial, especially when using quick and cheap diagnostic tests. For countries with low prevalence, targeting screening probably makes more sense. However, choose your targeted screening approach carefully: I performed a study recently where we found that reverting to our targeted screening approach would miss around 50% of carriers!
Stella Maimone (Buenos Aires, Argentina): “Infection control: the other side of the moon”
Stella was the first registered infection control nurse in Argentina. Most IC nurses in Argentina have been trained by her. She gave a general talk on IC in Latin America (LA) based mainly on the differences between Latin America and developed countries in IC. She noted that most LA countries ministries of health have some sort of infection surveillance systems including in Argentina. However, the data are not publicly available (at least in Argentina) which is a major difference between LA vs. USA and Europe.
Although LA countries are aware of the cost of HAIs, they have limited resources and it is not possible to reproduce the same IC policies that are implemented in US and UK (e.g. CDC guidelines) in LA. The reasons for that are: limited resources, different culture, LA people don’t like to be controlled (i.e. governmental regulations will have limited effect), and LA people think short term hence IC policies aimed at results in the distant future will not be adopted.
Hence for effective IC policies in LA, the limited resources of the countries/hospitals, the wider culture of society, and the ‘micro culture’ of the healthcare community must be taken into consideration.
Maria Clara Padoveze (University of Sao Paulo, Brazil): “Help! An outbreak!”
This was an interactive session with Q & A throughout. The informative talk covered outbreak definition and detection, but did not address outbreak control and infection control interventions in detail, which was a shame. Maria highlighted a useful website for performing quick literature reviews on various outbreaks from round the world: www.outbreak-database.com. This gives you an up-to-date (ish) report of outbreaks from around the world. If you register (free) you can access advance search where you can search per country for example.
Celeste Lucero (Argentina): “MDROs: a new world war”
This helpful overview began with an overview of how organisms acquire multidrug resistance. Celeste mentioned the WHONET-Argentina, which is a WHO Collaborating Centre for Surveillance of Antimicrobial Resistance in the country. Celeste offered a few examples including the CTXM-2, which is endemic in Argentina, and the emergence of CTXM-15 and OXA-163. She also mentioned that many Acinetobacter baumannii are now only treatable by Tigicycline and Colistin, and that rates of KPC have been increasing since 2010. To compound matters, Argentina had its first reported NDM-1 in 2013. I left the talk without a clear picture of prevalence of MDROs in Argentia, which may reflect the paucity of accurate epi data.
Martin Kiernan (UK): “Taking infection prevention to the next level”
Martin gave a talk on the UK experience in IC, citing examples of the impressive reductions achieved in the UK for MRSA and C. difficile, and the various interventions to achieve these reductions. He mentioned that the problem now is MDR Gram-negatives such as E. coli and Klebsiella pneumoniae. His talk focused on how to change the IC culture in a hospital, including getting everyone engaged.
Syed Sattar (University of Ottawa, Canada): “The role of high-touch environmental surfaces in the spread of HAI: strategies to minimize the risks”
The talk began by outlining the factors that determine the risk of transmission from an environmental surfaces: probability of contamination; ability of pathogen to survive on the surface; transmission potential (e.g. porous surfaces are poor at transmitting pathogens, hence focus more on hard surfaces); location and frequency of direct contact with the surface (e.g. via hands or mucous membranes). He then went to define which pathogens to focus on. He warned not to focus on the high profile pathogens or the “pathogen of the month” such as HIV or H1N1 as these are less resistant in the environment and easily killed by disinfectants. Pathogens to focus on are: C. difficile spores; norovirus and other non-enveloped viruses such as rotavirus; MRSA; Acinetobacter; VRE.
The remainder of the talk was around liquid disinfectants and wiping. He specifically highlighted the problem with disinfectants/wipes, which are effective at spreading contamination if they don’t actually kill pathogens. He outlined the results of one of his studies, where they tested a number of disinfectants with wiping action and found that all except one did not kill all pathogens and also did spread them to other surfaces.
Some key papers mentioned in the conference:
3- Sattar SA, Maillard JY. The crucial role of wiping in decontamination of high-touch environmental surfaces: review of current status and directions for the future. Am J Infect Control. 2013 May;41(5 Suppl):S97-104.
Having somewhat dipped in towards the end of ID Week 2013 due to the overlapping Infection Prevention 2013 Conference in London, I can’t begin to provide a comprehensive overview of such a large event. Instead, I’ve tried to summarize new data on two important areas: the epidemiology and control of multidrug-resistant Gram-negative rods (MDR-GNR) and the role of the environment in transmission. You can access all of the abstracts free online here. Also, the poster abstracts that I cite below are either individually hyperlinked or can be downloaded here.
Dr Kavita Trivedi (California Department of Public Health) gave an overview of CRE in the USA, which has now been reported in virtually every state. Whilst surveillance sites, methods and definitions are problematic, CDC are coordinating some useful emerging data. For example, an NNIS prevalence survey indicates an increase in CRKP from 1% in 2001 to 10% in 2011. Also, the Multi-Site Resistant Gram-Negative Bacilli Surveillance Initiative (MuGSI) is beginning to yield some data. Early results from four states indicate that CRE is 10x less common than MRSA in the population, predominantly from urine cultures (85%) from patients with co-morbitities (93%) with a low mortality rate (4%). The CDC CRE toolkit provides a practical overview of recommended interventions. Finally, the challenges outlined by Dr Trivedi included: long-term care; variable prevalence; unknown epidemiological associations of different strains and genes; and colonization duration.
A featured oral abstract by Bamburg et al. described an outbreak of NDM-producing K. pneumoniae affecting eight patients. The complex transmission map was dissected using whole genome sequencing, reminiscent of the NIH experience.
There was a useful oral session on ‘Identifying and Overcoming Challenges in Preventing Transmission of MDRO GNR’:
- 1207, Haverkate. A Dutch group found that Klebsiella carrying OXA-48 can appear susceptible in vitro, risking ‘silent transmission’ of both the gene and the organism. The mean duration of colonization was almost one year and modeling indicated that readmission of CRE colonized patients needs to be carefully accounted for.
- 1208, Mody. A cluster RCT in nursing home residents with urinary catheters or feeding tubes found that enhanced and preemptive isolation; ASC; and education led to a significant reduction in MDROs and CAUTI.
- 1209, Hayden. A bundled intervention (ASC and isolation; daily CHG bathing; education; and adherence monitoring) significantly reduced CR Klebsiella in three of four LTACs included in the study. The prevalence of CR Klebsiella was remarkably high: 45% of patients at baseline. Environmental contamination was not identified, so no enhanced cleaning and disinfection was implemented, which is different to the experience of NIH.
- 1210, Lewis. Varying the definition of ‘MDR’ made a profound impact on the proportion of patients requiring contact isolation, from 8-30%. Subsequent discussion with the authors indicated that the proposed MDR definitions developed by ECDC and CDC to be too sensitive for bacteria with less intrinsic resistance, such as E. coli. Perhaps a separate definition for the Enterobacteriaceae and non-fermenters is the way forward here?
- 1211, Apisarnthanarak. The implementation of chlorhexidine bathing plus a switch to bleach for environmental disinfection brought an outbreak of A. bauamannii in Thailand under control. But which worked?
- 1212, Barnes. A mathematical model indicated that hand hygiene is twice as important as environmental hygiene for interrupting A. baumannii, MRSA and VRE transmission. Whilst an awful lot of assumptions are required in this model, I can believe this 2:1 ratio in light of the following: “healthcare personnel are like small children: they touch everything and don’t always wash their hands” (Curtis Donskey) and “healthcare personnel hands are like very mobile shared surfaces” (Eric Lofgren).
- 740, Jamal. CRE rate: 3% of 2000 Kuwaiti clinical isolate; 15.9% of CRE NDM-1 producers.
- 746, Koper. A match made in hell between hypervirulent K2 Klebsiella and KPC; in vitro plasmid transfer demonstrated.
- 1578, Madigan. No CRE detected in 69 international patients at Mayo Clinic; 22% carried ESBLs.
- 1582, Johns. 50% of 66 MDR A. baumannii cases in Ohio in 2012 presented in first two days of admission, mostly admitted from extended care facilities, illustrating the ‘revolving door’ between acute and other healthcare facilities.
- 1586, Carrilho. 26% of 157 Brazilian CRE polymyxin-resistant, though polymyxin resistance was not associated with increased mortality.
- 1603, Drees. Remarkably, a survey from the SHEA Research Network indicates that 6% of hospitals do NOT isolate patients with CRE.
- 1609. Decker. A study of CRE colonization patterns indicates median colonization of 216 days (range 134-376). One patient was colonized for >500.
- 1611, Odom. CRE cultured from 12 (4.4%) of surfaces, predominantly sink drains.
- 1612, Fitzpatrick. Selective broth enrichment added 10% sensitivity for detecting CRE. Is the resulting diagnostic delay worth the wait?
- 1615, Lin. Chlorhexidine gluconate (CHG) daily bathing significantly reduces the number of body sites growing CRE, but several sites remain colonized.
- 1618, Cheng. CRE identified in 1.2% of 6533 rectal screens and faecal specimens in Hong Kong, which is lower than I would expect.
Reflections from MDR-GNR research
- We now have some intervention studies, but many include bundled interventions. We need more resolution on what works.
- The duration of colonization with CRE seems to be long, probably around 1 year on average. Is this enough for a “once positive, always positive” approach?
- Prevalence of CRE is variable around the USA, and in other parts of the world.
- There is poor resolution between the epidemiology of Enterobacteriaceae and non-fermenters.
- Most would agree that contaminated surface play an important role in the transmission of MDR non-fermenters such as A. baumannii. But is CRE an environmental issue? Some groups have found contamination and implemented enhanced disinfection, others have not.
- Should chlorhexidine decolonization be part of the intervention for MDR-GNR?
- Different research groups use different terminology and the meaning is sometimes obscured. International consensus is required.
Role of the environment in transmission
Dr Curtis Donskey (Cleveland) gave an excellent overview of ‘Environmental Controls for the Prevention of C. difficile Transmission’. Dr Donskey is one of the most active researchers anywhere in the world, focusing much of his attention on the role of the environment. Having established the importance of contaminated surfaces in the transmission of C. difficile, Dr Donskey explored emerging themes in addressing surfaces contaminated with spores covering conventional and automated terminal cleaning, and the impact of improving daily disinfection. The current challenges outlined included where to clean, how to validate “no-touch” automated room disinfection systems (NTD) to disentangle product claims from real-world performance, how best to engage environmental services and how to make disinfection easier in order to facilitate compliance.
- 347, Livorsi. Patients with a higher nasal burden of MRSA are more likely to carry MRSA at other sites and contaminate their environment.
- 348, Sitzlar. Useful stratification of MRSA/VRE room contamination rate by patient C. difficile status. Rooms of patients on precautions for CDI 3x more likely to be contaminated.
- 1393, Deshpande. One hospital found more C. difficile contamination in the rooms of patients who were not on precautions for CDI than in rooms of patients on precautions for CDI!
- 1394, Kundrapu. Suggests that the result would be better if those tasked with monitoring cleaning performance got their hands dirty and cleaned.
- 1541, Sunkesula. Reduction in VRE in new unit; attributable to no shared rooms and bathrooms in the new unit?
- 1685, Rose. A couple of carbapenem-resistant bacteria on public surfaces outside New York hospitals; I bet you it’d be higher in New Delhi!
- 1685, Havill. Extended survival of CRE on dry surfaces; will surprise some.
- 1690, Kirk. Almost no MRSA cultured from medication cabinets in isolation rooms. Direct plated swab lacks sensitivity?
- 1691, Suwantarat. Quantitative assessment of HCP contact with equipment and fomites helps to define high touch (risk?) items; medication chart highest frequency of contact (1 per patient hour) yet possibly also the least cleaned item.
- 1692, Hirsh. ipads (and other personal electronic devices) can become contaminated with pathogens; contact precautions should include an explicit instructions not to touch these items. (This was implemented at NIH during recent CRE outbreak there).
- 1695, Williams. Pathogens identified on the clothing of HCP at the BEGINNING of their shift! (Reminds me of Hayden article where VRE commonly found on the hands of HCP BEFORE they entered patient rooms.)
- 1697, Vassallo. Universal standard precautions didn’t stop impressive trend reductions. Time to abandon contact precautions?
- 1698, Mann. Cleaning survey response rate of 100% (unprecedented). EVS staff have something to say, if only we’d listen.
- 1700, Gerba. What’s for lunch in the hospital cafeteria? MRSA, enteric bacteria and spores, apparently.
- 1701, Wiemken. Wipes are quicker and easier than bucket methods. Why wouldn’t you? (Perhaps only due to lack of wetting reducing efficacy.)
- 1705, Boyce. The informal ‘standard’ for ‘clean’ is <2.5 cfu/cm2. This equates to 65 cfu/contact plate, which is almost 1/3 of the way to uncountable. Is this an acceptable standard for ‘clean’?
- 1706, Power. Contaminated neonatal incubator? An hour of UVC should do the trick.
- 1707, Horn. HPV for terminal room disinfection associated with significant reduction in CDI. Study design controlled for hand hygiene compliance, but time series analysis may have been more appropriate.
- 1708, Anderson. Is variation in UVC cycle time for room disinfection explained entirely by variation in room size?
- 1709, Uslan. Assessment of various Cu surfaces; I was unaware that you could apply Cu as a spray though have concerns over durability.
- Decolonization has been a hot topic since several high-profile articles have been published recently. It’s a shame that universal chlorhexidine was conflated with universal mupirocin in the Huang study; the two should be considered separately in my view. The potential for resistance to mupirocin is extremely high, whereas the risk for ‘resistance’ or continued reduced susceptibility to chlorhexidine is lower. However, an interesting finding from poster 1615 was that the measured CHG skin concentration (20-1200 mg/L) was MUCH lower than the applied CHG concentration (10,000 mg/L). This brings the subtly reduced susceptibility to CHG reported in MRSA into play. Both Dr Aaron Milsone (Hopkins) and Prof Mary-Claire Roghmann (University of Maryland) highlighted the importance of the need to ‘tend the human microbiome’ and to consider the ‘host-microbiome-pathogen’ interaction rather than the ‘host-pathogen’ interaction, remembering that decolonization can cause considerable collateral damage to the host microbiome.
- Dr Denise Cardo (CDC) delivered the SHEA Lectureship on HAI Science and Policy. CDC are streets ahead of any other government health agency in leading HAI science through the development of common, simple goals; accountability; transparency; efficiency and strategy. HAI science alone is not sufficient to influence policy; this requires congressional briefings, senate hearings and the use of the scientific and lay press. The recently published CDC threat report outlines how the (somewhat bleak) future may look. Most poignantly, Dr Cardo could not attend the conference and delivered her lecture remotely due to the government shutdown, which signals leaner times ahead for CDC.
- BUGG. Dr Anthony Harris (University of Maryland) presented the results of the ‘Benefits of Universal Glove and Gown’ (BUGG) study. This RCT with impressive compliance to screening, gloving and gowning showed a significant 40% reduction in MRSA but no significant reduction in VRE. The a priori primary outcome (a composite measure of MRSA and VRE acquisition) was non-significant. I’m generally not a fan of universal approaches, since compliance in the real world is likely to tail off when the spotlight of a large study fades. Indeed, poster 1696 showing a ‘dismal’ 20% compliance rate with gowning in the field sheds a shadow on the BUGG study.
- Dr Brad Spellberg (UCLA) gave a wake-up call on the future of antibiotics and resistance. Reflecting on the three things guaranteed in life (death, taxes and resistance), Dr Spellberg outlined the unfair fight between humans and bacteria: we’re outnumbered to begin with, and multiply much more slowly! Dr Spellberg’s recent papers in CID and NEJM outline the radical approach required to curb and reverse antibiotic resistance including embracing technology, rekindling R&D, preserving effective agents and exploring novel therapies. Dr Spellberg gave a fascinating insight from the 1960s revealing that it’s not the first time the antibiotic pipeline has dried. We need to learn from history and rekindle R&D before the pipeline dries completely. More importantly though, exploring non-antibiotic therapies, or novel applications of existing agents, has a more realistic chance of brightening the future of antimicrobial therapy.
I have a long flight to San Francisco to enjoy, which provides a perfect opportunity to relax and write my report from Infection Prevention 2013 Conference (Sept 30th – Oct 2nd 2013, London). The abstracts from the excellent submitted scientific material have been published as a free supplement in the Journal of Infection Prevention.
Opening lectures – Tricia Hart, Dale Fisher, Michael Gardam, Hugo Sax and Martin Kiernan
Following a short opening address from newly appointed IPS patron Prof Tricia Hart, exhorting us to put our patients before the numbers, Prof Dale Fisher from Singapore took the stage to talk about gaining organizational buy-in. With seamless reference to ‘Pirates of the Caribbean’ throughout, most memorably “It’s not the problem that’s the problem; it’s your attitude to the problem that’s the problem” [Capt Jack Sparrow], Prof Fisher gave useful advice on gaining buy-in from all stakeholders, not just administrators. An interesting idea was to incentivize hand hygiene compliance by offering a substantial tax rebate. Another was to embrace the power of the media rather than running away scared. But, whatever you do, don’t be seen as a ‘rigid, dour zealot’.
Dr Michael Gardam from Canada was outstanding in his content (including perhaps the first ever hand gelogram) and delivery on using front line ownership to deliver patient safety. His resonating theme was ‘culture eats strategy for breakfast’. Dr Gardam drew a thoughtful parallel between healthcare and raising children: challenging, private, rewarding, unpredictable, fun. This illustrated the ‘individuality’ of healthcare; each patient is different and should be treated individually. Equally, to achieve effective culture change, you need to empower the changee.
Prof Hugo Sax from Switzerland challenged the traditional approach of: perform hand hygiene ‘education’ then if that fails, educate some more and if that fails, make education mandatory! A consideration of fundamental human limitations was helpful: our finite capacity to process information per time unit; we are more likely to behave when being observed; and physiological responses affect our behavior (e.g. olfactory cues). These so-called ‘human factors’ must be embedded in our approaches to promote hand hygiene compliance.
To round off the morning’s lectures, Martin Kiernan delivered the EM Cotteral Lecture, revealing the life and times of the urinary catheter. Typically animated and innovative (including live tweeting as he was speaking), Martin outlined the challenges surrounding urinary catheters, including non-infectious risks. There is a remarkable lack of data and heterogeneity of practice for such a high-risk healthcare intervention. Although not quite finishing on a song, Martin did finish on a poem.
Submitted oral presentations: hand hygiene compliance and MRSA control
Paul Apler (Deb Ltd) presented an electronic system for monitoring hand hygiene compliance. The numerator is accurate, with each pump of hand gel logged electronically, but the denominator is derived from an algorithm for anticipated hand hygiene opportunities. The initial data look great, but the success or failure of the system depends on the accuracy of the denominator, which may need some tweaking for new settings. It does seem that the subjectivity and Hawthorne effect of hand hygiene monitoring would be reduced or perhaps even eliminated through automating the process.
Carolyn Dawson (University of Warwick) gave an overview of her research considering triggers for hand hygiene, with overtones of Prof Sax’s opening lecture. Inherent (“urgh”) triggers are more powerful than elective (“taught”) triggers hence inherent activities result in better compliance. We need to harness these fundamental human factors to achieve the highest possible rates of compliance. Carolyn has written an engaging blog-report of Infection Prevention 2013, which includes more details on her research.
Next up, I presented some work on MRSA admission screening at St. Thomas’ in London. An informal poll of the audience revealed that, surprisingly, the majority thought that targeted screening would detect less than 50% of carriers. Our study calculated that reverting from universal MRSA admission screening to a targeted approach would result in 75% (almost 22, 000) less screens but 45% (262) undetected MRSA carriers admitted. Is this enough to reconsider scrapping universal MRSA screening and returning to a targeted approach?
Debbie Weston (Kent) experienced a sizable outbreak of mupirocin-resistant MRSA, affecting 144 patients over 10 months. Amongst other interventions, the team made a sensible switch from mupirocin to fusidic acid and octinisan for MRSA decolonization and screened staff for MRSA carriage. Five staff carriers were detected, which could have been a factor in the continuation of the outbreak. This outbreak brings into sharp focus the risk of universal application of mupiriocin to ICU patients in a recent US study.
Multidrug resistant Gram-negatives
An important forum for discussing the challenges presented by multidrug-resistant Gram-negatives began with Prof Peter Wilson (UCLH) summarizing:
- Issues driving the “next MRSA”: antibiotic abuse in humans & animals; gastrointestinal carriage; complex, challenging sources; and rapid transmission.
- [Scant] evidence for effective interventions: screening; isolation; staffing; enhanced disinfection (consider hydrogen peroxide vapour); antibiotic stewardship; ward closure (perhaps).
- Research needs: gastrointestinal carriage rates; importance of imported cases; selective digestive decontamination (SDD); human vs. animal transmission; how best to improve cleaning.
Craig Bradley (Birmingham) then related his experience of controlling outbreaks of MDR A. baumannii highlighting the importance of environmental disinfection, and Alice Nutbourne (King’s, London) warned that empirical antibiotic therapy may be ineffective for an increasing proportion of Gram-negative sepsis cases.
Medical stats with Tim Boswell
Dr Tim Boswell (Nottingham) provided a useful, practical overview of how to tell whether an observed difference is due to chance. Covering theory, an overview and appraisal of available software and worked examples, this session provided a framework for understanding the difference between clinical and statistical significance.
Copper surfaces, “no-touch” automated room disinfection (NTD) and single rooms
Prof Tom Elliot (Birmingham) presented the impressive and ever-accumulating evidence for the introduction of copper surfaces in healthcare. Useful to note one cited paper from the 1980s showing that brass door handles were less likely to be contaminated than stainless steel ones, so the concept is hardly new. The data for copper surfaces are now impressive, with the Salgado study suggesting clinical impact. However, I still have questions over acceptability, durability and cost-effectiveness.
Gail Locock (Maidstone) then continued the estates theme with a view from her hospital, which is 100% single rooms. This iconic image perhaps best explains the reason why the switch to 100% single rooms was made, with the patients “so close tougher they could hold hands”. Whilst the infection prevention benefits of 100% single rooms are obvious, challenges include: patient visibility and associated safety, managing dementia, complacency, cleaning turnaround times, auditing compliance with hand hygiene and cohorting difficulties. Gail’s conclusion: pros and cons!
Prof Dale Fisher concluded the estates theme by addressing whether it is time to turn to “no-touch” automated room disinfection (NTD). Prof Fisher outlined the rationale for considering an NTD system; principally the ‘prior room occupancy’ data combined with the fact that conventional methods do not reliably eliminate pathogens. Several different NTD systems are available (mainly hydrogen peroxide vapour or aerosol, and ultraviolet C or pulsed-xenon), each with advantages and disadvantages. Technology can help, but you need to understand the limitations. In a way, NTD systems have redefined the standard for hospital hygiene, but workflows need to be adjusted if they are to be successfully implemented.
Submitted oral presentations: ‘Get Stoolsmart’ and hub contamination
The impressive and Twitter innovating Coventry IPS team gave an entertaining overview of their ‘Get Stoolsmart’ campaign, aiming to return clinical judgment to front line clinicians (with overtones of Dr Gardam’s opening lecture).
Dr Maryanne Mariyaselvam (Kings Lynne) found that 90% of needle-free IV connectors were contaminated with bacteria whereas only 33% of open hubs remained contaminated after flushing. What’s the answer? ”Scrub the hub” or new technology (including the connector impregnated with an antimicrobial under development by Dr Mariyaselvam and colleagues)?
Infection Prevention and Control in Japan – Prof Kobayashi
Prof Kobayashi (or ‘Kobayashi-sensei’!) provided a historical perspective on the development of an IPC programme in Japan. As a cardiac surgeon turned IPC champion, Prof Kobayashi has decades of experience to relate. Ultrasonic chlorhexidine baths for hand hygiene turned out to be a bad idea due to Gram-negative contamination, but the implementation of hand gels, link nurse programmes and temporary side rooms in Japan under the expert stewardship of Prof Kobayashi were years ahead of their time.
International Forum on Infection Prevention and Control
Internationally renowned speakers representing Asia (Prof Dale Fisher), the USA (Robert Garcia), Europe (Prof Hugo Sax) and England (Carole Fry) presented their biggest IPC successes and challenges:
It was encouraging to hear the experts celebrating their success, sharing ideas and embracing the challenges. From my viewpoint, the common challenge is the threat of CPE, which have the potential to spread globally like wildfire and make antibiotics virtually redundant.
Peter Hoffman on wipes
There’s been an explosion in the use of detergent and disinfectant impregnated wipes for hospital disinfection. Parents of young children in particular will understand the convenience of wipes over “wet bucket” approaches. But how do the data look in terms of efficacy? Peter Hoffman (PHE) outlined the challenges for wipes including: variations in microbial susceptibility, dealing with soiling, achieving adequate contact time with a small amount of wetting, large / intricate areas, choosing an appropriate active chemical and the dangers of sequential wiping transferring contamination. Importantly, Peter demonstrated that adding a sporicidal chemical to a wipe does not necessarily make a sporicidal wipe. Depressingly, it seems that choosing disinfectant wipes currently relies on manufacturers’ data using non-comparable testing. Conventional suspension tests and surface tests are meaningless for wipes so an accepted standard test for wipes (like this one from the Maillard Cardiff lab) is required urgently.
Keynote addresses – Jane Cummings, Aidan Halligan
The Chief Nursing Officer, Jane Cummings, spoke on unraveling and harnessing the potential of the complex ‘new’ NHS, aided by this useful infographic. The address included discussion on a new initiative: ‘6Cs Live’, which looks like an invaluable resource. The CNO concluded with a powerful patient-centred video entitled ‘Empathy’.
The video aptly introduced the theme of Prof Aidan Halligan’s address on rediscovering lost values in the NHS. Prof Halligan was disarmingly honest and forthright with the need to put patients first, poignantly citing Martin Luther King: “Our lives begin to end the moment we become silent about things that matter”. Focusing on empathy and compassion, and having the courage to challenge poor behaviour in a ward environment that can sometimes feel like a warzone is challenging and mistakes will be made. But try we must!
Submitted oral presentations – CPE at King’s and HPV at Tommies
Anita Verma (King’s, London) discussed the challenges of managing an outbreak of VIM-producing CPE on a paediatric unit affecting 11 patients in 2012. The outbreak response included the development of a detailed care plan, enhanced cleaning and transfer guidance for other hospitals. Despite several challenges (including poor adherence to IPC standards; suboptimal cleaning and disinfection; lack of awareness by caregivers, staff and visitors; and young patients in nappies), the outbreak was successfully controlled.
David Tucker (Guy’s and St. Thomas’, London) described a comparison between the length of time and cost of disinfecting rooms and bays using conventional methods of hydrogen peroxide vapour (HPV). Surprisingly, the HPV process time (including pre-cleaning) was only marginally longer for rooms and bays, and HPV was marginally more expensive for rooms and cheaper for bays. These findings are at odds with the general perception that HPV takes considerably longer and is much more expensive than conventional methods.
Clostridium difficile – search and destroy
Search – Dr Simon Goldenberg (Guy’s and St. Thomas’, London) addressed some problematic epidemiological definitions for C. difficile, which result in confusion and make true “CA-CDI” difficult to identify. Relatively recent data on C. difficile testing suggests that ‘you’d be better off flipping a coin than using some toxin EIA tests for CDI diagnosis’. Fortunately, DH diagnosis guidelines are now clear!
Destroy – Myth-busing Dr Jimmy Walker (PHE) provided some invaluable advice on choosing a sporicide active against C. difficile. Practically speaking, Dr Walker reminded us of the need for effective cleaning prior to disinfection for both disinfectant activity and aesthetics, and to look out for material compatibility problems when using sporicides. Specifying appropriate in vitro tests for sporcidies is challenging, but a 60 minute contact time is completely unrepresentative: you’d be lucky to achieve 6 minutes in the field; 6 second is probably more realistic. Dr Walker urged us not to be passive purchasers, but to check and challenge manufacturers’ (sometimes bogus) sporicidal claims.
Closing lectures – Barry Cookson, Phil Hammond, Didier Pittet and Julie Storr
Prof Barry Cookson delivered the Ayliffe Lecture on the past, present and future of MRSA. Prof Cookson described the 1970s as the decade of complacency, the 1980s of re-emergence, the 1990s of dawning realization, the 2000s of reactivity and the 2010s of uncertainty. My alternative view is: 1970s close shave; 1980s warning signs; 1990s unchecked; 2000s action, finally; 2010s ‘post’ MRSA era. The conclusion was to learn from the past to safeguard the future, with Prof Cookson remaining fearful of future failure if effective surveillance systems are not in place and maintained.
Dr Phil Hammond lit up the room with his insightful and, at times, downright hilarious commentary on speaking the truth to power (for example, his silencing of Andrew Landsley on Question Time), on not commoditizing healthcare; on restructuring the NHS; on dark stories about gagging whistleblowers; and on transparency. His summary: the ‘top-down’ restructuring of the NHS has failed; we need to develop care partnerships with our patients.
Newly appointed patron Prof Didier Pittet inspired us to begin with the end in mind, focusing on what we want to be and do, followed by final uplifting words from the Julie Storr, the IPS President.
Infection Prevention 2013 provided some useful food for thought and discussion:
- Try new ways to achieve culture change (for example, empowering your culture changees [Gardam], embracing the media [Fischer], and ‘putting the love back into infection prevention and control’ [the irrepressible Coventry IPC team]).
- Where and when can automation help (monitoring hand hygiene compliance, terminal disinfection)?
- What on earth do we do about MDR Gram-negatives, specifically CPE?
- How to do more for less, maximize the opportunities of the ‘new’ NHS, whilst retaining compassion and empathy as core values?
My head is full and my wallet is light following an enjoyable week in Geneva for the 2nd ICPIC conference (25th – 28th June 2013). I missed out on the inaugural ICPIC in 2011, so I was pleased to make the 2nd ICPIC. I was a little concerned that it would be a “hand hygiene fest”, but the programme had a good balance between hand hygiene and other areas of infection prevention and control. The conference had more than 900 delegates from 89 nations with 97 oral presentations and 427 posters. Congratulations to the organizing committee for arranging an interesting and stimulating conference. The conference abstracts are freely available in an ARIC supplement and the slides can be purchased by contacting the conference organizers.
Sadly I was unable to clone myself and attend every session, but this will give you a flavour…
TUES 25TH JUNE – OPENING SESSION
The opening session focused on viruses with pandemic potential, with an impressive introduction from some Genève luminaries and a personal video from Dr Margaret Chan (WHO Director General).
David Heymann – The legacy of SARS
Dr Heyman presented an engaging first-hand overview of the early reports of SARS, illustrating that it was predominately a healthcare-associated infection. The legacy of SARS according to David Heymann:
- Improved global surveillance, for example, the advent of new surveillance methods and networks such as Google outbreak software.
- “Research ready” capacity. The emergence of new microbial threats promotes the requirement for a research network ready and waiting to swing into action, such as the Oxford University Institute for Emerging Infections.
- Economic impact. SARS cost Hong Kong 4% of GDP.
- Understanding animal reservoirs. HIV, SARS, Avian Influenza, MERS-CoV (?) and most other pathogens with pandemic potential have emerged from animal reservoirs.
Wing Hong Seto – Infection control before and after SARS
Dr Seto’s thesis was that the spread of SARS in hospitals was due to poor basic infection control practice, evidenced by his own institution’s low rate of staff infection stemming from his enthusiastic education and awareness campaign. Put another way, sloppy infection control cost healthcare professional’s their lives. Dr Chan stated earlier that “the thermometer won the war against SARS”, which resonated with Dr Seto’s “getting the basics right” message. The experience of SARS has resulted in an increase in focus on infection control in Asia region, resulting in more investment, higher infection control staff : bed ratios and centralized expert committees. However, there has been some overreaction too, with very expensive structural changes to hospitals without proper consultation. Dr Seto’s enthusiasm truly lit up the stage.
Laurent Kaiser – influenza, coronavirus and emerging viruses: can we predict the unexpected?
A detailed overview of the genetic basis of these pandemic viruses that are associated with respiratory disease, aerosol / droplet spread, seasonal patterns, an RNA genome and rapidly emerging strains. The most interesting part of the talk for me was a consideration of how long it takes to “humanize” an animal virus. Whilst it’s difficult to be sure, it seems that it takes decades (or perhaps even centauries) for the necessary amount of recombination and mutation to occur for a virus to jump to humans and spread efficiently. For example, the H1N1 virus seems to be a mosaic of three viruses that may trace its origins to the 1918 pandemic. In this age of almost instant phylogeny, it may not be long before we can start watching viruses evolve in real time.
Keiji Fukuda – Latest news from MERS-CoV and H7N9
Dr Fukuda (WHO) gave a brief historical view of HIV, SARS, H5N1 and H1N1 to illustrate how a pandemic response looks in relation to the two current threats: H7N9 and MERS-CoV. A relatively small number of N7N9 (132) and MERS-CoV (70) cases have been reported so far, but their high mortality rates are alarming. Interesting unanswered questions:
- Are we at a suitable level of readiness to respond?
- How should we name pandemic viruses?
- How do we handle intellectual property that emerges during pandemic response?
Robert Wachter – Embedding infection prevention into medical training and the patient safety agenda
Dr Wachter explained that the patient safety movement began with infection control, but is now predominant in the US. Infection control should seek to embed itself within the core values of patient safety: quality and value. Dr Wachter explained some seminal moments in the development of the patient safety movement: the realization that medical errors were killing the equivalent of a jumbo jet of Americans each day and that zero is possible. Perhaps it would be helpful to see non-compliance with hand hygiene as a medical error?
WEDS 26th JUNE
Hyde Park corner debate: decrease of MRSA in the UK successful infection control or natural decrease? Stone v Wylie
Unusually, I found myself in disagreement with both the pro and con position presented in this debate!
Dr Stone laid out the case for the pro, largely based on this study. The main conclusions from the study were that MRSA bacteraemia and C. difficile rates fell in association with increased use of alcohol based hand products and soap, respectively, but MSSA bacteraemia rates did not fall; and that the Department of Health Implementation Teams and the Healthcare Act were associated with MRSA bacteraemia. It’s odd that rates of MSSA bacteraemia did not fall in conjunction with the increased use of alcohol based hand products. Also, I wonder whether a “breakpoints” type model would have been more suitable for this dataset?
Dr Wylie tried to convince us that the national reduction in MRSA was due to natural variation. He used the wax and wane of an unusual MRSA clone in the 1970s in Denmark as evidence that clones come and go. However, this was controlled by a focused national intervention, which rather defeated Dr Wylie’s argument. He offered three alternative plausible explanations:
- Incompletely understood interventions. [Not an alternative explanation per se, just saying that the decline was associated with the interventions, just not in the way that Dr Stone said.]
- Changes in host immunity.
- Changes in antibiotic use.
The one alternative explanation that Dr Wylie mentioned only in passing was increased use of chlorhexidine. This seems to be a much more plausible alternative explanation, so I’m not sure why this was not explored in more detail. It would also go some way to explain the relatively rapid decline in EMRSA-16 vs. EMRSA-15.
It just seems totally implausible that a national campaign to control MRSA would happen to correspond with a natural decline in MRSA. There will always be some uncertainty in interpreting epidemiological trends. Bradford-Hills famous criteria are oft cited, but worth noting that Bradford-Hill once said “my criteria cannot provide indisputable evidence – they help us to make up our minds”.
The impact of the US Veterans Affairs initiative: too nice to be true? Samore v Bonten
Dr Samore presented a robust case that the interventions throughout the VA network in the US explained the reductions in this NEJM study by Jain et al. He included a fair overview of the study limitations (principally no control group!). Interesting to note that the admission prevalence of MRSA was around 15% in the Jain study, compared with just 2% in London. Whilst there are important differences in the patient groups admitted to VA hospitals in the USA and a London teaching hospital, the magnitude of the difference is striking and may explain in part the large reductions in transmission achieved.
Dr Bonten took the opportunity to play devil’s advocate for several recent high-profile MRSA papers. I would have preferred a more detailed critique of the Jain et al. study, which was, after all, the subject of the debate! Dr Bonten’s group have published a reanalysis of the Jain data challenging their findings. Dr Bonten concluded, rather depressingly, that we still don’t have any proven interventions to control MRSA, apart from universal mupirocin and chlorhexidine, or “selective digestive decontamination”. Neither strategy get my vote due to the obvious risk of the development of resistance; we need to work harder to evaluate the most effective ways to target our precious remaining antibiotics in order to preserve their activity.
Antoine Andremont – The gut microbioma: mother of all troubles?
This fascinating lecture outlined the challenges associated with resistant bacteria in the gut. The gut houses a phenomonial number of bacteria (up to 1014 cfu per mL), predominantly non-pathogenic anaerobes (1010), other commensals (106-109) and resident enterobacteria (106). To qualify these numbers, the population of Paris is around 106 (number of enterobacteria) whereas the number of humans that have lived on earth for the past 3 million years is 1010 (number of non-pathogenic enterobacteria).
Antibiotic resistant enterobacteria can be found in the gut, comprising somewhere between 0 to 100% of all enterobacteria, which varies over time with diet and antibiotic usage. The presence of resistant enterbacteria is likely to result in widespread shedding into the environment based on VRE data.
The carriage of resistant bacteria in the gut is probably impossible to eliminate, but could be addressed by the following:
- Reduce the use of antibiotics.
- Increase hygiene and sanitation.
- Decolonization (although attempts to decolonize using antibiotics and probiotics have failed thus far).
- Moderate counts of resistant bacteria in the gut. There are several approaches here, for example the co-administration of a recombinant enzyme to inactivate antibiotics in the gut or the use of an “antibiotic sponge”.
George Daikos – The how’s and where’s of colistin resistance
Dr Daikos explained how polymyxins have been ‘reinvented’ to tackle multidrug-resistant Gram-negative rods, citing data from this Medscape report:
The antibiotic works through electrostatic interaction with the cell membrane predominately via lipopolysaccharides which facilitates the update of colistin and subsequent cell death. Resistance can be intrinsic, adaptive or acquired, and heteroresistance has been reported. Heteroresistance could be greatly underreported: a recent SENTRY study found that 23% of multidrug resistant Acinetobacter were heteroresistant to colistin.
Colistin resistance is emerging fast in certain areas; 23% of K. pneumoniae are now resistant to colistin in Greece. The fact is, we still have a lot to learn about how to use colistin most effectively, it’s mode of action, resistance mechanisms and how to detect reduced susceptibility in the clinical lab.
Matthew Samore – C. difficile in the community: community-onset or silent reservoir?
Dr Samore began with some entertaining analogies to illustrate the various ways to understand the interchange between hospital and community C. difficile: Gwyneth Paltrow in Contaigon, an Iceberg, a Straw Man and a Bathtub! Several studies identify apparently rising rates of CDI in the community yet carriage by healthy community members remains rare (2-3%). Combined with the finding that C. difficile colonization increases with length of stay make me think that CDI remains a predominantly hospital problem with some community-onset cases. Indeed, the recent JAMA Intern Med study of apparent CA-CDI only evaluated healthcare-exposure for three months prior to the CDI episode, and most patients had some healthcare exposure. I was surprised that Dr Samore did not mention high rates of carriage in neonates, which seems to be a genuine community-based reservoir doubtless resulting in a background of community acquisition of C. difficile.
There’s perhaps a parallel with MRSA here. For a long time, people talked about “community-acquired” MRSA, when it was really MRSA transmitted in the hospital manifesting in the community. However, there did come a phase shift in the epidemiology of MRSA with the emergence of distinct CA-MRSA strains that began to transmit outside of hospitals. So, we shouldn’t rule out CA-CDI as a possibility, but I don’t think we’re there yet.
Walter Zingg – C. difficile control in the hospital
Dr Zingg considered the various factors in the transmission of C. difficile: contamination of patients’ skin, hands, air and surfaces; proximity to other patients and colonization pressure. The control interventions highlighted were isolation, hand washing, single use thermometers, environmental disinfection using a sporicide (including adjunctive hydrogen peroxide vapour where feasible) and antibiotic restriction. I was surprised not to hear of the role of molecular diagnostics in C. difficile control. The switch to more accurate molecular diagnostics has facilitated improved identification of infected patients, and hence more successful isolation.
Or should I say, the ‘Infection Control Dragon’s Den’. Just like the TV show, 15 innovations were granted a 3 minute pitch followed by two minutes of quick-fire questioning from the expert panel and audience. Prof Pittet ensured that each presenter stuck to their 3 minutes, which was entertaining in itself. Five finalists were selected for an extended pitch the following day and a winner selected by the expert panel. A classic quote from Einstein set us off: “If at first the idea is not absurd, it is not good”! I’ve listed the finalists below along with some details of all 15 pitches:
- The winner: ‘A novel immediate pre-operative decolonization strategy reduces surgical site infections.’ Pre-operative decolonization using photodisinfection combined with chlorhexidine bathing. High compliance, well tolerated and saved money. My only problem is that it was difficult to delineate the relative impact of photodisinfection (novel innovation) from chlorhexidine (already well established). Nonetheless, a worthy winner!
- Second place: ‘A novel antiviral technology for air filtration.’ An external antiviral layer for masks. The agent is only effective against enveloped viruses and the need was not well defined. Is this to prevent penetration of infected viruses through the mask or to reduce the risk of hand contamination when removing the mask?
- Third place: ‘A novel antibacterial material for transparent dressings.’ A small trial (n=10) of a polyurethane dressing with antimicrobial properties.
- Fourth place: ‘Can Dav132, a medical device targeting an adsorbent to the late ileum, decrease significantly the impact of antibiotics on the fecal microbiota?’ A medical device to “mop-up” antibiotics in the gut with huge potential to suppress resistant gut flora.
- Fifth place: ‘Infection Control Enclosure (ICE) pod: meeting the need for more single rooms’. [COI – I am listed as a co-author on this one!] A way to increase single room capacity in a multi-occupany bay setting.
The other pitches:
- ‘Reduction of resistance by sublingual administration of antimicrobials.’ A gutsy musical presentation of an old paper from the 1970s. The only problem was, not a shred of data to support the innovation!
- ‘A new generation of hybrid biomaterials for antimicrobial medical devices.’ Impregnated silicon for medical devices to reduce bacterial adhesion.
- ‘Electronic hand hygiene monitoring for the WHO 5-moments method.’ An automated way to monitor hand hygiene compliance by placing a chip in each dispenser to measure usage in real-time and compare with expected usage patterns generated by an algorithm.
- ‘Evaluation of the efficacy of a novel hydrogen peroxide cleaner disinfectant concentrate.’ ‘Accelerated’ hydrogen peroxide is an impressive product, but it’s been around for a long time so has no place in the innovation academy!
- ‘A new genre of surface disinfectant with long residual bactericidal activity.’ A polymer antimicrobial surface film that can be impregnated with various antimicrobials (I think – wasn’t particularly clear on this point)!
- ‘Development of an electronic dashboard to assist surveillance’. The e-dashboard ticks some important boxes for me, not least because it’s free! However, how does it compare with proprietary systems in terms of functionality?
- ‘Combining electronic contacts data and virological data for studying the transmission of infections at hospital.’ Tagging patients and staff with RFID badges to track movements and then trace proximity (though not contact per se). Useful Harry Potter “Marauders’ Map” style technology.
- ‘New holistic approach to determine the infection risk profile of a hospital; visualized in an easy-to-read plot’. A way to produce a visual, fairly intuitive ward-level report to easily identify areas for improvement. A useful tool, but lacks the novelty of other contenders.
- ‘Organisational transformation – the application of novel change techniques & social media understanding to motivate infection-prevention activists.’ A pitch from the Infection Prevention Society using collaboration focused on social media to effect organizational change following a “pre-mortem” self-assessment.
I particularly enjoyed the Innovation Academy. The Dav132 antibiotic gut “sponge” got my vote as the most important innovation.
THURS 27th JUNE
Meet the experts (Boyce and Dettenkofer): Controversial issues about environmental cleaning and disinfection
Dr Dettenkofer began with a framework for understanding hospital cleaning and disinfection needs. His position is that low-level disinfection is the main requirement. However, the presence of C. difficile spores means that a sporicide (i.e. high-level disinfectant) is necessary on occasion. So, is the requirement for hospital disinfection high or low level disinfection? Dr Dettenkofer talked briefly about the debate over whether surface disinfection is required at all in hospitals, when cleaning (without the use of a chemical disinfectant) is often sufficient. Interesting to hear that Dr Dettenkofer has begun to use a liquid hydrogen peroxide disinfectant in his hospital. Finally, the question of whether a two-step process (cleaning followed by disinfection) is necessary. It’s difficult enough to get good compliance with one round of cleaning or disinfection, let alone assuring adequate coverage of first a cleaning agent, then a disinfectant. Effective combination products are required urgently.
Dr Boyce discussed:
- What is the ‘best’ surface disinfectant? He considered aldehydes, QACs, phenolics, chlorine releasing agents, hydrogen peroxide and peracetic acid. The conclusion: all have pros and cons!
- So, how to assess cleaning performance? Visual assessment, microbiological cultures, ATP or fluorescent markers. These are not mutually exclusive and, again, all have pros and cons.
- Finally, which “no-touch” room disinfection system to use? Hydrogen peroxide vapour, aerosolized hydrogen peroxide, UVC, pulsed-xenon UV and other systems are available. You guessed it, all have pros and cons!
Control of hyperendemic Carbapenem-resistant Enterobacteriacae
Abdul Ghafur – The Indian perspective
A passionate presentation by Dr Ghafur beginning with 50% attributable mortality in his neutropaenic patients due to CRE resulting from carbapenem and colistin abuse; mortality for pan resistant CRE approached 100%. Dr Ghafur discussed some of the underlying problems in India: poor sanitation, high rates of carriage of resistant bacteria (80% CR Acinetobacter and 40% CR Klebsiella), reflecting on the fact that tight local antimicrobial prescription will not save you if everyone else is sloppy. How to treat pan-drug resistant CRE? “Pentatherapy” using a 5 drug cocktail and a prayer. (Actually, there is probably some synergy between colistin and other antibiotics so pentatherapy isn’t as daft as it sounds.)
Yehuda Carmeli – An Israeli perspective
Israel experienced a dramatic initially clonal national outbreak of CRE (KPC CC258) in 2006. Analysis of data from the outbreak indicated that compliance with cohorting correlated tightly with CRE transmission; more data that getting the basics right works. The risk-based screening that was implemented detected a low prevalence of carriage (5% from long-term care facilities, 0.5% from other high risk groups) but was considered worthwhile to prevent outbreaks. Dr Carmelli raised several points for discussion:
- Media interest. It seems to me that the media can be a friend or foe in dealing with outbreaks and wider healthcare issues. If left unbriefed, they will be a foe. But if properly briefed, they can be a powerful ally.
- Emergence of different CRE genes (OXA-48 and NDM-1) in Israel with different epidemiological associations than KPC.
- Dealing with the long-term care facility reservoir.
- Non-compliance with basic infection control.
- “Eye off the ball” syndrome, where hospital administrators only respond to current threats.
The national successful response in Israel is an encouraging success story. However, Israel has a population of 8 million, with only 31 hospitals. Can successful national control strategies be implemented in larger countries with an inferior healthcare infrastructure and national debt problems such as Greece and Italy?
Achilles Gikas – The Greek perspective on CRE: from surveillance to control
Dr Gikas described the development of the CRE epidemic in Greece with overlapping outbreaks of VIM and KPC carriers, and how CRE is now a “frequent flyer” travelling around the world. Reassuringly, there are some local success stories in Greece where focused interventions have reduced rates of CRE, but, mindful of Dr Kulakkattil’s comment that “no hospital is an island”, concerted national efforts are required to grasp this rampaging Hellenic bull by the horns.
Environmental decontamination with hydrogen peroxide vapor – does the effect evaporate over the Atlantic? Perl v Huttner
Having spent some 10 years researching this particular topic, needless to say I was looking forward to this debate. The debate was not particularly well framed. Was this about most of the studies of HPV (and all of the controlled studies with a clinical outcome) coming from US hospitals? Or that many European countries have a lower proportion of single rooms, which makes the application of HPV more challenging? Or a wider debate about whether to consider “no-touch” disinfection (NTD) systems at all? I felt that Dr Perl addressed the more general questions while Dr Huttner focused on HPV studies, which rather took the wind out of the sails of the debate.
Dr Perl summarized data that pathogens are shed into the environment, they survive for extended periods, persist despite conventional cleaning and disinfection and improving conventional methods helps, but transmission continues. Hence, NTD systems and specifically HPV are warranted in some circumstance. Dr Perl acknowledged the lack of RCTs but showed convincing data that HPV eliminates pathogens from surfaces and reduces transmission, and fulfils Bradford-Hill’s criteria of causation.
Dr Huttner began like Dr Perl by considering some things that evaporate over the Atlantic: big cars, big guns and flavoured coffee to name but a few! His American wife gives him an unusually sharp perspective on trans-Atlantic issues. Dr Huttner had clearly done his homework and read the various HPV studies in detail. He presented a series of good points, although I didn’t feel that he constructed a particularly coherent argument. To address some specific points:
- Dr Huttner described the compliance rates with hand hygiene in the Manian et al study (showing that enhanced terminal disinfection using multiple rounds of bleach or HPV) as ‘unrealistically high’. I’d be interested to hear what Dr Manian would make of this challenge…
- Regression to the mean as a potential confounder was highlighted in several outbreak reports and the before-after Boyce et al. study (fair criticism).
- A detailed critique of the Passaretti et al. study. Too many individual points to list here, but, in my view, none undermined the key finding: that admission to a room disinfected using HPV reduces acquisition risk from the prior occupant.
- Industrial involvement in studies leading to bias. It’s true that industrially funded studies are more likely to have a positive outcome, but these studies wouldn’t have happened without industrial funding. Going forward, I expect to see more studies like Manian et al. without any industry involvement.
- Feasibility in terms of room access, time, restriction to terminal room disinfection and recontamination. You certainly won’t be able to get to every room you’d like to with an NTD system, but feasibility studies show you can reach a fair proportion even in a busy hospital. The issue of recontamination is a “straw man” argument: when NTD systems are used for terminal room disinfection, recontamination by the incoming patient is irrelevant; their usefulness is to break the chain of transmission from the prior room occupant.
The short debate (30 mins) did not allow time for the authors to present a rebuttal, which was a shame, but it was a stimulating session.
FRI 28th JUNE
Controlling ESBLs – a global perspective
Jean-Christophe Lucet – Europe
Dr Lucet began by demonstrating a startling increase in the proportion of invasive isolates that carry ESBLs in Europe comparing 2005 with 2011. He reviewed data that ESBL-producing K. pneumoniae is much more likely to be transmitted in hospitals than ESBL-producing E. coli, perhaps due to an increased capacity for environmental survival. Effective interventions are difficult to recommend due to lack of RCTs, outbreak settings (and regression to the mean), publication bias and control bundles. However, Dr Lucet concluded:
- Hand hygiene: yes.
- Active surveillance cultures and contact precautions: equivocal.
- Cohorting: yes during outbreaks.
- Environmental control: less important than for other pathogens.
- Selective digestive decontamination (SDD) / universal use of chlorhexidine: equivocal. My view is that SDD should not be used – the indiscriminate use of antibiotics will drive further resistance.
Wing-Hong Seto – Far East / Asia
Carriage rates of ESBLs in E. coli and K. pneumoniae are alarmingly high in parts of Asia, reaching >50% in India and Vietnam. Dr Seto suggested that single room isolation is more important for Gram-positive vs. Gram-negative bacterial pathogens based on relatively higher recovery of Gram-positive bacteria from the hospital environment. However, lactose non-fermenting Gram-negatives such as Acinetobacter seem to ‘mimic’ Gram-positive bacteria in terms of their environmental survival, and even the Enterobacteriaceae can survive for days to weeks to months on surfaces. So, I would argue that priority for single room isolation should be dictated by an assessment of local epidemiology and risk, not the survival properties of various bacteria.
Andrew Stewardson – Australia
Carriage rates of ESBL-producing bacteria are lower in Australia than in nearby Asian countries (<10% in the hospital population and <5% in the community). Dr Stewardson presented some interesting Australian data showing that rigorous implementation of standard precautions and antibiotic restriction programmes can result in impressive reductions of ESBL producing K. pneumoniae in hospitals.
My first ICPIC was an enjoyable experience. Highlights included the opening session learning lessons from SARS, the entertaining innovation academy and some grim updates on the ‘rampaging Hellenic bull’ that is CRE. Regretfully, I didn’t get to see a single poster and missed few concurrent sessions (including the review of best papers by Eli Perencevich and Andreas Widmer – they’ve published their slides here). Of all the analogies presented at the conference, I think the most useful was the ‘Infection Control Football Club’ by Dr Sheldon Stone. Hand hygiene is the goal keeper (i.e. last line of defence). But you won’t have a winning football team with just a goal keeper. No matter how good they are, they will never stop every shot.