Can we halve GNBSI? The crowd say no…!

I participated in another pro-con debate recently up against fellow Reflections blogger Martin Kiernan during a Webber Teleclass. The question for the debate was “Can we halve Gram-negative BSI?” (I was arguing that we can). We ran a live Twitter poll and the outcome: 59% of the 22 respondents voted that no, we can’t halve GNBSI.

The slides from my talk are here.

My argument had two main themes: that there is a sizeable preventable portion of GNBSI and we have a lot to go for, and that we need a new approach to preventing GNBSI that will require new models of collaborative working across acute and non-acute health and social case.

The image below maps out the drivers of GNBSI. Some of these are modifiable (e.g. hydration and UTI, devices, antimicrobial stewardship), and some are not (e.g. deprivation [ok technically modifiable but beyond the scope of most IPC teams!], seasonal variation). The aim here is to identify those drivers of GNBSI that are modifiable and come up with practical interventions that could make a big difference.

Figure: Drivers of Gram-negative BSI.

Hydration is a good example. The most common source of E. coli BSI (which accounts for most GNBSI) is UTIs. We know that poor hydration is an important risk factor for UTI. So if we can improve hydration – in hospitals and outside – then there’s a good chance we’ll reduce UTI and in doing so reduce E. coli BSI.   

Antimicrobial stewardship is another. If we can improve the management of Gram-negative infections in the community through appropriate therapy outside of hospital admissions, then you reduce the chance that they’ll progress to a GNBSI.

I can’t tell you for sure that we can halve GNBSI. But we must try to prevent the preventable GNBSIs!

Should we routinely audit hand hygiene in hospitals? The crowd say no…!

I had the privilege of participating in the IPS Autumn Webinar series yesterday, in a debate with Dr Evonne Curran on whether we should routinely audit hand hygiene in hospitals. It was good fun – and highlighted some important points about the strengths and limitations of hand hygiene audits – and audits generally for that matter!

Here’s my case for routine hand hygiene auditing in hospitals (you can register (free!) and view the webinars here):

My key arguments were that:

  • Hand hygiene is really important, and one of a range of interventions that we should be routinely auditing to launch focussed improvement work.
  • There are key sources of bias in hand hygiene auditing (see below). However, these can be reduced with optimised methodology.
    • Observation bias (aka Hawthorne effect) – where behaviour is modified by awareness of being observed. For example, if I stand over you with a clipboard and a pen, you’re more likely to do hand hygiene.
    • Observer bias – difference between the true value and the observed value related to observer variation. For example, poor trained auditors will result in variations in reported practice due to observer bias.
    • Selection bias – when the selected group / data does not represent the population. For example, only doing hand hygiene audits during day shifts won’t tell you the whole picture.
  • Hand hygiene audits are a legal and regulatory requirement (in England at least).
  • My own experience is that optimised hand hygiene auditing methodology can deliver a performance indicator that can identify areas of poor performance and drive focussed improvement initiatives.

At the end of the debate, two thirds of the live audience voted against doing routine hand hygiene audits in hospitals. Put another way – I lost! I am taking the view that the audience voted against the concept of inaccurate auditing returning unrealistically high level of compliance, rather than against properly monitored and measured auditing, which can help to fuel improvement.

If nothing else, I hope the debate made the point that poorly planned and executed hand hygiene auditing is doing nobody any good – and may be doing harm. If we are going to do hand hygiene auditing, it should be using optimised methodology to deliver actionable information that is put to work to improve hand hygiene practice.

Can we halve Gram-negative BSIs by 50% by 2021? The crowd say “No”

Most of those casting their vote supported Martin’s (somewhat pessimistic) view that we can’t halve Gram-negative BSI by 2021 (see the figure, below).  Let me first give you my own, unspoiled opinion (written before the results of this survey were known).  I was intending to vote for option 3 (the English can’t, the Dutch might) but I am not even sure of that; actually, I believe that neither the English nor the Dutch can.

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Can we really halve Gram-negative BSIs (GNBSIs) by 2021? Kiernan vs. Otter Mk II

The UK government has recently announced their ambition to halve the rate of Gram-negative BSIs by 2021. Looking at the latest mandatory reporting dataset (see Figure 1 below), you can see why. Impressive reductions in MRSA BSI and C. difficile, but a notable increase in E. coli BSI. And this combined this with worrying data around increased antimicrobial resistance in Gram-negative bacteria from the ESPAUR report. In this post, Martin Kiernan and Jon Otter present both sides of the argument as to whether Gram-negative BSIs can be reduced by 2021, with comment from Andreas Voss and Marc Bonten! And you get to vote on which side of the argument you come down on after reading the arguments. Let battle commence…

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Reflections from Infection Prevention 2016


As is now becoming traditional, I thought I’d share a few reflections from the recent IPS conference in Harrogate. Fantastic to see the submitted abstract published, full and free, in a Journal of Infection Prevention supplement.

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