The light of day

Well, I’m two days in to my first ECCMID meeting, and what can I say, it’s huge. There also seems to be a bit of IPC creeping in, however one thing has struck me. There has been debate as to whether some interventions, for example chlorhexidine washing, is effective but in reality it seems to be common with many interventions in IPC that the real issue isn’t the intervention, it is getting people to reliably implement it that is the real issue.It is the same for pre-op prophylaxis, warming etc., etc., etc. We give feedback on SSI rates to surgeons, but what about the others who have an influence on the bundle that should be implemented. Not seen anyone look at performance of individual anaesthetists or other theatre practitioners in implementing antibiotic prophylaxis, warming, supplemented O2 and glucose control yet they are the gatekeepers of these interventions.

Whether something works in a lab or is theoretically possible seems to me to be a bit academic if no-one will do it. I saw a study today presented by Stephan Harbarth, who was defending screening and decolonisation (I prefer suppression) for Staph infection prevention and the compliance was <50% although there seemed to be an effect. Andreas Voss countered that if we cannot implement an intervention we should not be putting it in place, a fair point. In my humble opinion we really need to undertake some good qualitative studies that look at why interventions that may be (and sometimes that absolutely are) effective are not implemented despite the evidence. Is it that we are unable to personalise the outcome (for staff) or that (in the case of patients) that the perception of risk to the self is low, despite the evidence, as in smoking and alcohol intake. Perhaps we should have to describe how to implement reliably as part of the research and development process for the intervention. Otherwise are we just producing yet another publication or free paper that will not reliably and consistently be implemented and that will never really see the light of day?

C’est difficile

Two new interesting papers in ICHE, both of significance I think. The first from Kings’ College Guy’s and St Thomas’ in London examines the degree of environmental contamination from patients with diarrhoea and toxigenic C. difficile but undetectable toxin. These patients are called a “potential Clostridium difficile excretor” in some papers. In this study, Biswas and colleagues (including Jon Otter and Simon Goldenberg) demonstrated that C. difficile was recovered from 49% of rooms from patients producing toxin and from 34% of the rooms of “potential Clostridium difficile excretor” group. Call me ‘Mr Picky’ but at what level of contamination does ‘potential’ become actual? 13% of sites tested in the ‘potential’ group were positive (around half that of the CDI group). So, actual infection seems to cause more contamination, which if patients are having more bowel movements I would accept, but the level of contamination from those without toxin production is, I would say significant (not forgetting that the toxin test is as reliable as flipping a coin).  The authors are right, all excretors are a risk and we should not shrink from efforts to detect them. Thinking further, It would be interesting to see if the level of contamination could be linked with the frequency of bowel movements (and possibly the Bristol stool chart score?). Should be possible if nursing records are reliable (ahem..). Without getting too graphic there would likely be a splatter factor. Should we increase cleaning frequency for patients with multiple type 7 stools in a day?

The second paper looked at the association between hospital room square footage and acquisition of  CDI, showing an Odds Ratio of 3 for every increase of 50 square feet. Interesting, possibly effective cleaning is more difficult in a large space, the cleaning equipment is recontaminating or any disinfectant is losing efficacy? What are the implications for multi-occupancy bays as in the UK? Still lots to learn about the environment.

Time to really recognise the importance of Prevention

Pretty worrying editorial in Clinical Infectious Diseases this month, discussing the issue of Polymixin resistance in Acinetobacter. So basically no treatment options and an attributable mortality of 30% from an organism that isn’t normally that virulent. Although these organisms do not seem to be causing too many problems in the UK, it is a different story in Asia. New therapeutics are some way off and there have been a few false dawns. So how about a real concerted effort to prevent infections and transmission in the first place. A good honest look at infection rates, realistic audit and feedback of hand hygiene compliance (instead of the non-credible >100% usually trumpeted), the same for assessing the effectiveness of cleaning, instead of the rose tinted spectacles that are the usual method. Infection prevention and control activity isn’t a PR activity for a while until new options for treatment come to fruition it may be all that we have.

PPE – help or hindrance?

Much attention on the use (and misuse) of PPE over the past months. I have always thought it to be a good thing if used well but this paper seems to suggest that universal use of gloves and gowns could be a good thing, suggesting that the 25% of staff that contaminate their clothing by only using PPE for patients with known pathogen carriage could be reduced by universal use of PPE. Whilst I agree that those not known to be carrying organisms ‘of interest‘ are a significant issue (you only know what you know after all), I also worry about the over-use of PPE and the possible blase attitude that this brings. As we all know, PPE can be a hazard if not removed in a logical order that minimises contamination to the wearer (‘correct’order TBA..), however given that training is er.. often less than comprehensive, would universal use reduce the risk? Maybe of  contamination of uniforms, but would other risks increase? I’m not totally convinced that clothing contamination is a significant risk to anyone but the wearer at the moment.

Pseudomonas – I keep getting that ‘sinking’ feeling

Yet another study has just appeared in AJIC ‘In Press’ that reports on a long-term, discontinuous ‘outbreak’ of Pseudomonas (see http://www.ajicjournal.org/article/S0196-6553%2815%2900138-8/abstract). Once again everything points back to the sinks in the unit and a reusable washbasin for hairwashing. So all back to water and practice issues around it. Water is dangerous you know, nearly 100% of murderers and theives have consumed it in the 24 hrs preceding their crimes and it is the leading cause of drowning. Seriously though, wouldn’t we expect to find Pseudomonas in a sink trap? It is how it gets to the patient that is the issue. I was in a hospital overseas recently where mop-heads were conveniently placed either side of the sink to soak up splashes from the basin. So, why were there splashes? The sink trap was just a hole and so the staff had placed big grilles over the bottom of the sink to prevent items going down and blocking the sink. Turning on the tap produced a very attractive set of fountains, a bit like at the end of ‘Oceans 11’. Nuff said

Rescuscitation

Time to wake this sleeping blog up I think. Plenty of material out there. I’m just back from a trip to Asia, including the APSIC meeting in Taiwan. What struck me was the huge amount of interest in the environment. The meeting kicked off with a keynote on the subject and looking through the programme there was a session on environmental contamination in virtually every concurrent. Acinetobacter is the primary concern and they’ve not got started on C. difficile yet (mainly helped by not looking for it.. I wish I’d thought of that)