As we warm up for world hand hygiene day tomorrow, it’s a good time to have a talk about gloves. I challenge you to go onto a hospital ward and time how long it takes before you see some questionable glove practice. It won’t be long before you see somebody coming out of a room used by a patient on some transmission based precautions with gloves on. Or somebody commuting around the ward with gloves on. Or somebody putting gloves on in preparation for patient care who can’t quite articulate why. So, as many of us launch new patient care pathways in the next phase of the pandemic, and as the national IPC manual has just been published in England, it’s a really good time to talk about when we don’t need to use gloves, which is most of the time!Continue reading
One of the questions that we often ask ourselves is whether carriers of CPE (and other MDR-GNR) can de-isolated. Most of the guidelines are pretty non-committal on this point due to lack of evidence. Some new guidelines from ESCMID-EUCIC address this issue head on. But, unfortunately, the answer is that de-isolation of CPE carriers, particularly over the course of a single hospitalisation, isn’t going to work because there’s no effective decolonisation method.
Although there’s some controversy about whether or not we should apply contact precautions (by that I mean single room isolation, enhanced PPE, enhanced disinfection etc) all the time for all organisms, it would be a brave hospital to eschew contact precautions for CPE carriers. And so the question of whether and when we should ‘de-isolate’ patients with known CPE is an FAQ. And so enter a recent study in CMI comparing the spontaneous apparent loss of colonisation with various CPEs, concluding that KPC carbapenemases seem to hang around for longer than NDM carbapenemases, but both almost always last for the duration of a single hospitalisation.
The PHE Toolkit recommends pre-emptive isolation for patients who meet one of the risk-factor triggers for CPE screening. Furthermore, the pre-emptive isolation recommended in the Toolkit should be continued until three negative screens are obtained, each separated by 48 hours. In what is best described as a data-based thought experiment, colleagues from Imperial tested the impact of various CPE screening strategies on the burden of contact precautions generated.
They say that things come in threes, so following hot on the heels of blogs about MRSA and other MDROs in nursing homes, I was struck by a recent outbreak report of CRE associated with nursing homes the Netherlands.
Following the admission of a patient from a Greek ICU, a nosocomial transmission of CRE (ST258 KPC K. pneumoniae) occurred. By the way, this occurred despite the hospital recognising the risk of CRE at the time of admission from the Greek ICU, perform an admission screening and implementing pre-emptive contact precautions. Then the index patient was transferred to a nursing home, where subsequent transmission occurred to four other patients.