CRE: coming to a hospital near you


I thought for quite some time about whether the title to this post ought to be a statement or a question. I decided on a statement: pretty much wherever you are in the world, I am certain that CRE is now one (hospital) degree of separation from you.

I gave this talk yesterday at the imaginatively named “Darling Bugs of May” IPS conference, and you can download my slides here. I’ve given similar talks before, but the whole thing took on greater significance now I have had some first hand experience of making decisions around the management of CRE patients.

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Reflections from the front line: why doctors don’t listen to the ‘impending doom’ of antibiotic resistance


Guest blogger and Acute Medicine trainee Dr Nicola Fawcett (bio below) writes…I’ve just returned from the European Conference for Clinical Microbiology and Infectious Diseases (ECCMID) in Copenhagen. I got the chance to pop into a few sessions on my first love in Microbiology – Stewardship and behaviour change. Before you all think I’m crazy, I’ll just add that I’m actually a trainee in Acute Medicine – I started out in the overlap area of how you change antibiotic use in acute admissions.

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What does it take to get an infection prevention and control service into shape?

mrsaWhilst the organisation of an infection control service isn’t everybody’s cup of tea, it is mine now. So, what are the key elements of a successful programme? A thoughtful review in Lancet ID penned by an all-star cast (including Zingg, Holmes & Pittet to name but a few) provides a framework for answering this question. Their systematic review yielded 10 key components:

  1. Organisation of infection control at the hospital level;
  2. Bed occupancy, staffing, workload, and employment of pool or agency nurses;
  3. Availability of and ease of access to materials and equipment and optimum ergonomics;
  4. Appropriate use of guidelines;
  5. Education and training;
  6. Auditing;
  7. Surveillance and feedback;
  8. Multimodal and multidisciplinary prevention programmes that include behavioural change;
  9. Engagement of champions;
  10. Positive organisational culture.

None of these are especially surprising, or that difficult to implement. It’s strange in a way that we know from multiple studies that high bed occupancy results in more transmission (specifically of MRSA). So why don’t we just reduce the rate of bed occupancy? If you account for the extended length of stay for patients who become infected, it would probably result in a net increase in patient throughput. Similarly, understaffing results in more transmission (again, specifically of MRSA). So why don’t we just make sure we hit adequate levels of staffing? I suspect the answer here is short-sighted accountancy combined with a genuine lack of the right staff to fill the necessary vacancies.

I’ve always found it a bit odd that the mere act of performing surveillance and reporting the results back to wards reduces HCAI – but there’s a fair amount of data behind this. I suspect it has to do with the type of people we are dealing with: busy healthcare professionals. If their unit’s rate of MRSA (or whatever) is, in the politest possible sense, in their face, they’re more likely to do something about it.

Finally, nurturing a positive organisational culture is crucial but somewhat philosophical. How do you measure whether your organisation has a positive culture? Perhaps perception is reality here, so the best approach is probably to consider organisational positivity as a highly transmissible infectious agent!

How to assess scientific posters: a practical guide

Posters are a hugely important part of scientific congresses. The submitted abstracts that get accepted as oral presentations are always only a fraction of the science available at conferences. And which abstracts get selected as oral presentations are, to a degree, at the whim of the abstract assessment committee and procedures. So, there will be some gems amongst the posters that have the potential to change practice.

I gave a talk at IPS today: a practical guide to assessing scientific posters. You can download my slides here. But they will only tell part of the story. The idea was for the session to be a practical workshop to arm those who are new to infection prevention and control with the tools to maximize their conference experience in terms of accessing submitted science.

I covered the publication process: concept -> research -> abstract -> poster -> paper -> “post-publication peer review”. It was interesting to think in more detail about what makes a good poster. Clearly, first and foremost, a poster must be visual. If it doesn’t look good visually, then it’s not a good poster. That said, what looks “good” is somewhat subjective, but I think some basic themes emerge in terms of visual presentation:

  • Eye catching – draws the viewer in
  • Graphical, not text based
  • Not cluttered
  • Good use of colour
  • Clear ‘flow’ from one section to the next
  • Key findings communicated clearly
  • Contains more detailed information for those that want it
  • Correct size for the board (check the guidelines!)
  • Not an essay / epic; it’s designed to stimulate discussion
  • No intricate fonts that are difficult to read
  • Watch out for fuzzy low-res graphics
  • You can’t include all your data – be selective

And then there’s the scientific content. Really, this is the same question as what makes a good abstract or, indeed paper. The following criteria may be useful in this regard:

Table: what makes a good poster (or abstract, or paper) in terms of content?How to assess a poster_cropped

So, I hope the participants found this session useful.

High levels of antibiotic resistance and low levels of ‘antibiotic literacy’ in the general public are on a dangerous collision course

MRSAPhoto credit: CDC, Janice Haney Car.

Guest Blogger Dr. Rodney E. Rohde (bio below) writes: The U.S. Department of Health and Human Services (HHS) has identified the reduction of healthcare-associated infections (HAIs) as an Agency Priority Goal for the Department. HHS is committed to reducing the national rate of HAIs by demonstrating significant, quantitative, and measurable reductions in hospital-acquired central line-associated bloodstream infections and catheter-associated urinary tract infections (1). In this national context, recent data show that Americans visit the doctor approximately 12 million times each year to get checked for suspected staphylococci or MRSA skin infections. Estimates are that 1 of every 20 hospital inpatients will contract a HAI (2).  This is roughly 270 deaths per day by one estimate – think of an airplane disaster with no survivors every day as a comparison. It appears that more people in the US now die from MRSA, especially healthcare acquired, than from HIV/AIDS.

MRSA incidence and the low levels of literacy about antibiotic resistant infections in the general public are on a natural collision course. The health implications for society are startling and this brewing public health storm should be a wake-up call for all involved in the prevention and treatment of MRSA and other antibiotic resistant infections. Traditional medical approaches to infection control, antibiotic prescribing and usage, and how the healthcare practitioner relates to the public in general, and to individuals in particular, are no longer adequate in light of this growing healthcare emergency. It has been my experience that individuals who are diagnosed with MRSA infections (and other HAIs) need an informed healthcare professional to explain a number of complicated issues to them to help the individual understand the dangers of these nasty antibiotic resistant infections. This, in turn, will lead to greater acceptance and adoption of infection control and prevention.

For example, I conducted a study for my dissertation that details the experiences of ten participants who have been diagnosed with MRSA (3). Briefly, this study provides a new model of how a person with MRSA in the general public learns and adapts to the infection. Their experiences emerged to create critical implications for practice and research. Almost all individuals had important advice for professionals about the nature of a consistent message for an MRSA plan. The embedded features of this plan were that people make the difference in these life-changing diagnoses. Likewise, all participants echoed the need for consistency of MRSA information and a step-by-step plan to manage the condition. Particular attention should be paid to the following areas: (a) the patient-healthcare provider interaction, specifically to create an open and non-threatening environment for learning to occur, (b) the delivery of critical information about the importance of having an MRSA diagnosis based on laboratory culture and antibiotic susceptibility testing, (c) specific education on what a MRSA infection looks like, including images/pictures and MRSA stories for patients, (d) the use of podcasts, digital video, and other electronic media (e.g. Facebook) to provide patient education beyond the initial MRSA diagnosis, (e) specific education about infection care, control, and prevention to themselves and others, and (f) guidance for individuals about sources of information and the credibility of sources. In regard to the use of podcasts and other electronic media, the message should be formed with a combination of stories from MRSA survivors and healthcare professionals to build a strong, synergistic media tool.

The implications for practice and research based on the literature and results of this study indicate a need to address issues of how the general public discovers, learns, and adapts to antibiotic resistant infections, especially MRSA. Likewise, this study emphasizes the critical importance of informing healthcare professionals and health educators (e.g. universities, schools, and other related institutions) about the need for better programs of patient education and continuing education surrounding the pre and post diagnosis of MRSA infections.  The participants in this study all emphasized the critical nature of talking to others that had already experienced MRSA with respect to getting an insider’s perspective on lessons learned. Finally, the participants in this study appeared to utilize self-directed learning and, to a lesser extent, transformational learning to challenge the healthcare system in regards to what content they needed about MRSA and how they might best learn to understand the disease. It may be possible to build on this desire to impact the healthcare system by inviting individuals who have experiences with MRSA to join a healthcare associated advisory committee.


  1. US Department of Health and Human Services, Health Care-Associated Infections.
  2. Department of Health and Human Services. HHS Action Plan to Prevent HealthCare-Associated Infections: Roadmap to Elimination.US Department of Health and Human Services, Washington, DC, USA (2012).
  3. Rohde, R.E. & Ross-Gordon, Jovita. MRSA model of learning and adaptation: a qualitative study among the general public. BMC Health Services Research, 2012, 12:88.

Guest Blogger Bio


Dr. Rodney E. Rohde is a Professor, Research Dean and Program Chair of the Clinical Laboratory Science program in the College of Health Professions, at Texas State University.

Dr. Rohde’s background is in public health and clinical microbiology. He has a bachelor’s degree in microbiology, a master’s degree in biology/virology and a PhD in education from Texas State. His dissertation was aligned with his clinical background: MRSA knowledge, learning and adaptation.

His research focuses on adult education and public health microbiology with respect to rabies virology, oral rabies wildlife vaccination, antibiotic resistant bacteria, and molecular diagnostics/biotechnology. He has published over 30 research articles and abstracts and presented at over 100 international, national and state conferences. He was awarded the 2012 Distinguished Author Award and the 2007 ASCLS Scientific Research Award for his work with MRSA. Recently, his work was the focus of an educational campaign regarding the important research focus of MRSA, which featured Dr. Rohde in a video by Texas State University that has been used by numerous media outlets. Learn more about his work here.

An environmental odyssey

Research from the Cleveland VA published in the ICHE special edition tells a fascinating story of sequential interventions to reduce environmental contamination with C. difficile. The research includes pretty much the whole battery of environmental interventions at our disposal: education of housekeepers, the introduction of a specially trained “A” team, ATP bioluminescence, fluorescent markers and UVC for “no-touch” disinfection. About the only thing missing is copper surfaces!

Before we get to the interventions, let’s just reflect on the fact that somewhere between 60-70% of rooms were contaminated with C. difficile after terminal disinfection in the baseline period. It’s little wonder that admission to a room previously occupied by a patient with C. difficile increased the chances of developing C. difficile infection! Related to this, there’s some interesting thoughts at the beginning of the discussion about whether there could be a “safe” level of C. difficile contamination. I discussed this in a previous blog post here.

The introduction of fluorescent marking with feedback did not eliminate the C. difficile environmental contamination, with 50-60% of cultures remaining contaminated. Similarly, the introduction of a UVC “no-touch” room disinfection system for terminal disinfection did not solve the problem, with 30-40% of cultures remaining contaminated. Only when daily disinfection was performed by a dedicated team and terminal disinfection was performed by EVS supervisors and/or the infection control team was the problem finally solved and C. difficile could no longer be cultured from surfaces. It’s disappointing that the intervention that worked in eliminating C. difficile room contamination comprised improvements in both daily and terminal cleaning, so it’s not possible to determine which was most important. It seems likely that a combination of the two did the trick.


Figure: sequential interventions to tackle environmental contamination with C. difficile.

The study used robust microbiology methods to sample the environment, comprising swabs plated directly onto selective agar, and gauze pads from the same surfaces cultured through broth enrichment. The % positive sites from the enriched gauzes was approximately double the swabs inoculated directly onto agar, demonstrating the value of broth enrichment for environmental sampling.

Another important study finding was that the effectiveness of room cleaning prior to UVC room disinfection was sub-optimal, indicating that the housekeepers were placing too much faith in the automated system, which is designed only to disinfect and not to clean.

So what does this odyssey mean? Firstly that a combination of interventions can be useful, and secondly, the extraordinary lengths required to eliminate C. difficile spores from the environment.

Article citation:

Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, Donskey CJ. An Environmental Disinfection Odyssey: Evaluation of Sequential Interventions to Improve Disinfection of Clostridium difficile Isolation Rooms. Infect Control Hosp Epidemiol 2013;34:459-465.