People have been talking in apocalyptic terms for years – probably decades – about the threat of AMR. But has this really materialised? MRSA BSIs are now rare in the UK, and C. difficile infections are rarer than they once were. But things are looking considerably gloomier in other parts of the world. For example, a frankly shocking study from a Greek ICU gives us a view of what a post-antibiotic apocalypse may look like…
While I had seen the WHO IPC Core Components, I have totally missed the great video they made. Thus, with no further comment, here the link to this well-made video.
Just in case that the link via the picture doesn’t work, copy and paste the following link into your browser: https://www.youtube.com/watch?v=LZapz2L6J1Q&feature=youtu.be
By now I had the debatable pleasure to be around for the birth of a few “superbugs”, but this one is clearly putting a lot of effort into reaching the top of the list. I believe (classical pessimist) that many institutions still ignore this new adversary (or are even unaware), and most certainly have no game-plan to prevent its introduction and consequent spread. In the MMWR publication the current recommendations for C. auris–colonized or infected patients were repeated, with only one change from previous recommendations, namely that a more effective (sporicidal) disinfectant is needed, but I seriously wonder who follows this guidance.
Thus, here it comes, another 30-seconds-questionaire. Why? Because I hope that you will prove me wrong and that we – the infection control people at the frontline – act on threat, instead of re-act once we are overrun.
Link to questions https://www.surveymonkey.com/r/QCK9RWS
Notes from the Field: Ongoing Transmission of Candida auris in Health Care Facilities — United States, June 2016–May 2017. Weekly / May 19, 2017 / 66(19);514–515 https://www.cdc.gov/mmwr/volumes/66/wr/mm6619a7.htm?s_cid=mm6619a7_e
Chowdhary A, Sharma C, Meis J. Candida auris: A rapidly emerging cause of hospital-acquired multidrug-resistant fungal infections globally. PLOS Pathogens https://doi.org/10.1371/journal.ppat.1006290 May 18, 2017
The World Health Organisation has updated its 2009 Guidelines on Core Components of Infection Prevention and Control Programmes. The report highlights eight ‘core components’ for IPC:
The Journal of Infectious Diseases has just published a special issue on norovirus, which is well worth reading. When norovirus strikes, there is an inclination to close the ward to new admissions at the earliest available opportunity in order to protect incoming patients. But when should the ward closure trigger be pulled? Not at all, as recommended by latest UK guidelines (risking continuation of the outbreak, fed by a steady stream of new victims…I mean admissions), when you get a single case of vomiting or diarrhoea (lots of unnecessary ward closure) or only when you have a lab confirmed outbreak on your hands (by which time the horse has already bolted and galloped through your hospital). The special issue included a useful modelling study providing some idea of the impact of various approaches to ward closure in response to noro outbreaks.
CRE are known to be adept at hitchhiking around the world, hence the focus on cross-border transmission in Europe. A startling example of this comes in a report from Poland result from the terrorist shootings in Tunisia. Two Polish nationals seriously injured in the shootings were repatriated following a 10-day stay in a hospital in Tunis, Tunisia. A grand total of four CREs were identified from the two patients!
Three of these were identified at the time of admission, so almost certainly originated in Tunisia. The fourth CRE was identified 10 days after repatriation to Poland. The authors suggest that the most likely explanation for this is poor sensitivity of admission screening. I venture, however, that it’s more likely due to in-hospital transmission in Poland, since the two patients were treated by the same staff.
Nonetheless, the most troublesome finding here is that at least three separate CREs were imported into Poland by just two patients. Can anybody find me a paper on the prevalence and epidemiology of CRE in Tunisia? No? Thought not. The implication here is that CRE is already far more established than feared in Tunisia and many other parts of the world!
As the owner of a relatively new beard (see picture below), I was alarmed to hear that my beard is probably as contaminated with faeces as a toilet brush. Fortunately, a Journal of Hospital Infection study from 2014 turns this on its head, showing that those wearing beards are actually less likely to be colonised with staphylococci!
Me and my beard
Whilst 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:
- Organisation of infection control at the hospital level;
- Bed occupancy, staffing, workload, and employment of pool or agency nurses;
- Availability of and ease of access to materials and equipment and optimum ergonomics;
- Appropriate use of guidelines;
- Education and training;
- Surveillance and feedback;
- Multimodal and multidisciplinary prevention programmes that include behavioural change;
- Engagement of champions;
- 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!
Jon asked me to write on his blog about our column (‘#15: Carbapenemase-producing Enterobacteriaceae’). As he kindly accepted my offer to co-write a column, I accept his to write this blog. I am calling this blog (which contains only my personal views): ‘Carbapenem-resistant Enterobacteriaceae (CRE): so what should an infection prevention and control team do now?’.
The problems with CRE are numerous, and the different actions needed to control or at least delay its endemnicity are likewise legion; the task can seem insurmountable. The approach being taken at national and international level covers much of what is needed. The question for individual infection prevention and control teams (IPCTs) is this: where do you begin to protect a healthcare system that has little capacity (and in some cases little will) to start to solve a problem that essentially has yet to arrive, that has at least 6 names (none of which can be spelt with confidence) and is absent from the CEO’s performance monitoring agenda? The additional challenge for IPCTs is this: it will be difficult for those working in clinical areas to believe that for all the improvement in infection prevention and control that reduced MRSA and C. difficile, still more is required for this new microbiological-kid on the block.
If I were still part of a hospital based IPCT this is where I would start…..
- Give it a name and stick to it in all correspondence / education / awareness sessions;
- Succinctly provide the reasons as to why this should be on everyone’s radar;
- Take a high-reliability approach to strengthening your healthcare system;
- Involve patient advocates.
1) Give it a name and stick to it…
As mentioned in the column (and many times by Jon) there needs to be a name that we can a) all agree on and b) conveys to non-microbiology people the problem and its seriousness. We have to stop fighting about what it is: CPE, CRO, CPE etc, etc. I don’t know who is on (or how you get on) the micro-organism naming committee, but I am beginning to think they need to make it more democratic and involve people who don’t understand microbiology. There is no perfect name that will keep all microbiologists happy, so let’s stop trying to find one. It’s important that IPCTs have a short name that denotes this big problem and makes this consistent in all documentation. (See this previous blog by Jon for more info on nomenclature surrounding this issue.)
2) Succinctly provide the reasons as to why this should be on everyone’s radar
I offer the following as a succinct summary for why this should be on everyone’s radar:
- These resistant organisms inactivate commonly used antibiotics. For any infected patient there are Few Treatment Options and there will eventually be No Treatment Options.
- They are spread Person to Person by touch, splash or contaminated equipment / environments.
- The resistance mechanisms are spread between different species of bacteria.
- They are difficult to detect when people are screened.
- They cause outbreaks, which are also difficult to detect and very costly to manage.
- Spread across the world makes at least some transmission here inevitable.
3) Take a ‘high-reliability’ approach to the problem in your area…
I am not going to regurgitate what is in existing guidelines but offer some high-reliability characteristics.
Sensitivity to operations: Given your patient/client population, consider how and why your healthcare system is vulnerable; share this information within your organisation.
Deference to expertise: Identify who you would go to for expert advice within and outwith your organisation should an incident arise. Keep contact details accessible.
Preoccupation with failure: Consider in which clinical areas you most likely to have an outbreak – visit these clinical areas and see if there can be changes to ways of working that would make outbreaks less likely.
Reluctance to simplify: Look for and don’t dismiss alert signals – this could be data that suggests you may have cases, cross-transmission, that you are insufficiently looking for possible cases or that your antibiotic prescribing data could make your healthcare system more vulnerable.
Commitment to resilience: Good as you and your team are – consider how you can make your systems better at preparedness, prevention and management of outbreaks.
4) Involve patient advocates
Patient advocates only really knew about MRSA and Clostridium difficile infection when the media told them. Letting patient advocates know that your team is alert to this emerging threat and that you are taking actions to prevent outbreaks may help. They can also lobby for leaders to take further action if required.
Here ends my first blog! Happy I think to receive comment, suggestions or improvements. Thanks for reading. Of note: Outbreak column 17 is on Cognitive Errors in Outbreak Prevention, Preparedness and Management.
Dr Evonne Curran bio:
Evonne is a practicing infection control nurse (since 1987) and a Doctor of Nursing (since 2010). She is the editor of the Outbreak column in the Journal of Infection Prevention (since 2011).