Promiscuous plasmids: a rapid reflection from ECCMID 2017

I came to ECCMID 2017 with a very specific question: do we need to think beyond ‘same-bug-same-gene’ horizontal transmission from a practical IPC view point in order to address the threat of IPC? The answer, unfortuantely, is yes!

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How much S. aureus is hospital acquired? Mk II

I posted a blog a couple of years ago (was it really that long!) on a fascinating study suggesting that only 1/5 of S. aureus in hospital patients is hospital-acquired. My key conclusion from that study was that the number of potential sources for S. aureus that the team investigated was inadequate to draw any firm conclusions (they didn’t include staff, surfaces, or visitors). I concluded that ‘the next frontier of transmission mapping must be a more comprehensive evaluation of other potential sources…’. The authors must have been reading, because this study from the same group was published recently in Lancet ID, which is a more comprehensive evaluation of other potential sources.

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Back to the floor..

flooringA little while ago I blogged about the excellent study from Nottingham that demonstrated significant VRE and MRSA contamination on socks used to prevent falls in the hospitalised elderly. This has been followed by another paper suggesting that shoe coverings undurprisingly become contaminated. So, what? How does this really impact on transmission? A new study from Curtis Donskey’s group has looked at hand contamination in patients directly relating to floor contamination. Continue reading

PPE for preventing highly infectious diseases

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The use of PPE and the protection of HCWs against highly infectious diseases was (and is) a topic of major importance, around the globe. The recent Cochrane review by Verbeek et al. was probably hoping to offer this “vital” information.

Unfortunately, they found no studies on the effects of goggles, face shields, long-sleeved gloves or taping on the risk of contamination. All they found was very low quality evidence, with high risk of bias and uncertain estimates of effect, that:

  • More breathable types of PPE offer more comfort without increasing the risk of contamination
  • Double gloving and CDC doffing guidance appear to decrease the risk of contamination, and
  • Active more than passive training in PPE use may reduce PPE and doffing errors.

Their conclusions are obvious: we need high-quality studies of the materials, their use and protective effects, safe ways of doffing, and the most adequate training to achieve safe use of PPE for HCWs in the presence of highly infectious diseases or those (even less infectious) that may cause severe harm to HCWs.

But what to do until than? My personal opinion is that we should only use PPE, we are used to and know how to use. First-time users, even if supplied with the best available products, will inevitably fail to remove the PPE without error. Consequently, institutions should have a stable selection of PPE, and in the case of preventing highly infectious diseases, a selected group of HCWs with continuous active training, as it is too late to start when the next epidemic is hitting our healthcare centers.

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Probable Person-to-Person Transmission of Legionella

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Ana M. Correia and colleagues (N Engl J Med 374;5 February 4, 2016) present a convincing case of person-to-person transmission of Legionnaires’ disease between son and mother. Seen the epidemiology of the two cases and the results of whole-genome sequencing, the only part of the short report I do not understand is the “probable” in the title. I wouldn’t know what else to include in order to call it “proven”.

Consequently, the question is whether this “new” transmission route has implication for infection control in the hospital setting. The mother had very close contact over an extended amount of hours with her severely coughing son, in a small and badly ventilated room. In opposite to HCWs who in this situation generally would wear a mask, she obviously used no personal protective equipment. Finally, while described as formerly healthy, no further details are given about the conditions possibly increasing the susceptibility of the 74-year old to Legionella.

Thus, while person-of-person transmission seems proven in the present case, I believe that the circumstances are unique and don’t require to change the present infection control measures taken in patients with Legionnaires disease.

Community MRSA preys on the poor and deprived

deprivation mrsa

As you can probably tell from the title, this post comes with a warning: it presents some rather “un-PC” data, but I’ll do my best to deliver it calmly and dispassionately! My old research team from KCL have just published a paper in PLOS Medicine on the association between social and material deprivation, and MRSA.

I’ve been interested in the dynamic between hospital-associated (HA) and community-associated (CA) MRSA for years (not least because it was the subject of my PhD thesis). I wrote a review several years ago on how community MRSA should be seen as a genotypic phenomenon with epidemiological implications. Using this framework, it is possible to get your head around CA strains of MRSA beginning to cause hospital-acquired infections. The aim of this study was to use a large collection of MRSA from across several regions of London to explore the transmission dynamics and epidemiological associations of HA and CA types of MRSA.

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3.. 2.. 1.. Zero. Great, the 48 hours are up!

Slide1We often see those tasked with finding suitable isolation facilities counting down to when precaustions can be discontinued and the ’48 hours clear’ of symptoms of loose stools or vomiting has almost become one of the most welcome statements heard in healthcare settings. No more contact precautions, no more disinfectants sloshing around, normality beckons.. Or should it? Continue reading