Year in Infection Control

May 2013-April 2014

Part I
Barry Cookson
University College, London,
United Kingdom
Declarations: Gojo, Ecolab, Qiagen

Part II
Christina Vandenbroucke-Grauls
VU University medical center, Amsterdam,
The Netherlands
Declarations: Biomerieux





Part 1: Barry Cooksons Topics
Improving evidence base in infection control
Modelling
Surveillance including Surgical, LTCF, Costings
Typing/Tracking Organisms
MRSA
Interventions
Screening/Suppression of MRSA
Hand hygiene

Part 2: Christina Vandenbroucke-Grauls
Topics

Antimicrobial resistance & antibiotic use
ESBL and carbapenemases
Clostridium difficile
The hospital environment
Gender
The Flos

Florence Nightingale (1820-1910)
Pubmed & reading 12 Journals


Blogs






Twitter

Sources for Presentations
www.micro-blog.info
Otter & Yezli
http://i-prevent.blogspot.nl
A.Voss
www.haicontroversies.blogspot.nl
Perencevich, Diekema, Edmond
Acknowledge Colleagues help
Sheldon Stone
Olga Paniara
Modelling and Big Data
Ben Cooper, Sarah Deeny & Julie Robotham
ICPIC (Eli Perencevich & Andreas Widmer)
ICAAC (Andreas Voss)
2013 ECCMID (Benedetta Allegranzi & Robert Skov)
presentations: complement, augment

Importance of ESCMID CPD library: many are
resource slides as little time to discuss in-depth
The Flos Special Award of the Year is
Cardiff University Library, Cochrane Archive, University Hospital Llandough.
1) Improving the quality of the infection control evidence
base: research inform guidelines/guidance
for policies for safer patient care

Tools for improving the evidence base
of scientific literature
CONSORT for randomized controlled trials (1996)
STROBE for observational studies (2007)
ORION for intermittent time series & outbreaks (2007)
Preferred Reporting Items for Systematic Reviews &
Meta- Analyses (PRISMA) for systematic reviews &
meta analyses (2009)
EQUATOR Network (2006)
http://www.equator-network.org/resource-centre/library-
of health-research-reporting/
STROME-ID (2014)
PLoS Med 10(8): e1001504.
doi:10.1371/journal.pmed.1001504
PLOS Med a champion and published previously
STROBE
Evidence that CONSORT & PRISM improved the literature
Published: August 27, 2013
Studies also show that the quality of reporting overall
remains suboptimal as not all journals endorse
or enforce the use of reporting guidelines

Comment: this is certainly true for infection control
and related journals
Reviewed outbreaks reported in So Paulo State, Brazil, &
verify compliance with mandatory outbreak notification
Explored potential for ORION to inform where need to to
improve competencies
Only 15/87 (17%) published outbreaks reported to authorities
Poor/Varied compliance with ORION categories
Background 32% , Objectives 75% , Participants 2%,
Setting 46% , Infection-Related Outcomes13%,
Interventions 52% & Culture-Typing 55%
Issue: Missed opportunity to stratify by Journals requirements
for ORION (expected for authors and evaluation by referees)
Pires et al, AJIC 42 (2014) e47-e53
PLoS Med 11(2): e1001603.
doi:10.1371/
journal.pmed.1001603
Differences in:
1) Publication format

2) Work processes

3) Author team
Management

4) Statistical methods.
Current
Emerging
Health Knowledge Ecosystems
Modelling!
PLoS Med 11(2): e1001603.
doi:10.1371/
journal.pmed.1001603
2) Modelling
A previous ECCMID Debate (2012)
Audience split on utility!
Everything should be
made as simple as possible,
but not simpler Albert Einstein
We argue that usability & stability of a model is an outcome
of the negotiation that occurs within the networks &
discourses surrounding it.





PLoS ONE 8(10): e76277.
doi:10.1371/journal.pone.0076277
PLoS Med 10(10): e1001540.
doi:10.1371/journal.pmed.1001540
We have found evidence to suggest that identification of
uncertainties, combined with their deproblematisation
can act to stabilise the role of scientific modelling in
decision-making
Clin Microbiol Infect 2013; 19: 993998


Mathematical models play an important role in helping
healthcare systems to respond to ongoing epidemics or
plan the logistics of various theoretical scenarios
Prediction & model-based management of
epidemics in their early phase are quite unlikely to
become the norm. far too complex to be predictable
BC: so do we guess: sometimes nothing else is available?
Flu: pnas.org/content/early/2011/10/24/1103002108.short
Internet biosurveillance systems can detect an outbreak
of an infection more rapidly than ever before.
BC : this may be a bit premature?

The Flos Honorary Award of the Year goes to
Prof Tim Berners-Lee
Inventor of the World Wide Web
25
th
Anniversary
3) Surveillance
Lancet Infect Dis 2014;14: 16068
Dengue & Influenza reviewed

Complement not replace existing systems

Many issues described e.g.
Lack of access to internet
Populations vary in internet use and Health-seeking
behaviour (BC: sample migration e.g. Facebook?)
USA poor sensitivity and spatial resolution
necessary to detect small, localised flu outbreaks
Also see Big Data FT article
Big data: are we making a big mistake?
FT Magazine: March 28, 2014: Tim Harford
Googles estimates of the spread of flu-like illnesses
were overstated by almost a factor of two. Google cared
about correlation rather than causation
The End of Theory: with enough data, the numbers
speak for themselves .. hopelessly naive where
spurious patterns vastly outnumber genuine discoveries.
When it comes to data, size isnt everything.
Non random.. sampling error USA twitters
are disproportionately young, urban/suburban & black
(Sample migration; Super tweeters?)

Cape Town Sunday Times
Lancet Infect Dis 2014;14: 16068
Journal of Hospital Infection 86
(2014) 34e41
Referral to:

Observed rates
Supra Regional
specialist
Hospitals
Created
Same
Collective
Murchan et al,
EMRSA-16 spread in
England and Wales.
J Clin Microbiol
2004; 57: 345-346.

HAI results, ECDC PPS 2011-2012

HAI prevalence:
Overall: 13829/231459 patients with 1 HAI
HAI prevalence: 6.0%
Country range: 2.3%-10.8%
15000 HAIs; 1.1 HAI/patient
HAI present at admission: 23%
Same hospital: 55%
33% surgical site infection
HAI during current hospitalisation:
76% of HAIs, prevalence: 4.5%
Median time to onset of HAI: 12 days
Microorganism reported: 45.9%
Prevalence antimicrobial use for treatment of hospital
infection: 6.4%
95% of patients with HAI received >=1 antimicrobial on
day of survey

Source: ECDC PPS, 2011-2012
(1) incl. C. difficile infections 3.6%
(2) incl. clinical sepsis 5.3%
23%
19%
20%
11%
8%
6%
4%
10%
Pneumonia/LRTI
Urinary tract
Surgical site infection
Bloodstream
Gastrointestinal (1)
Systemic (2)
Skin/Soft tissue
Other/unspecified
Type of HAI
30 countries (29 EU/EEA countries
+ Croatia), 33 PPSs (networks)


2014:12;71.
|
Observed vs predicted HAI prevalence by country,
ECDC PPS 2011-2012
0 2 4 6 8 10 12 14 16 18 20
Latvia
Romania
Lithuania
Slovakia
Bulgaria
UK-Wales
UK-N. Ireland
Malta
Hungary
Czech Republic
UK-Scotland
France
Germany
Ireland
Luxembourg
Estonia
Croatia
UK-England
Austria
Italy
Slovenia
Poland
Cyprus
Belgium
Sweden
Netherlands
Finland
Norway
Spain
Greece
Denmark*
Iceland
Portugal
Patients with HAI (%)
Observed HAI prevalence (%)
(with 95% confidence interval)
Predicted HAI prevalence (%)
(based on case-mix)
http://www.ecdc.europa.eu/en/publications/Publications/he
althcare-associated-infections-antimicrobial-use-PPS.pdf
Structure & process indicators:
percentage of single room beds

Single room beds in participating hospitals (%): median = 11.1%
Source: ECDC, 2012 (ECDC PPS data as of 23/11/2012)
0 20 40 60 80 100
N of single room beds*100 /Total beds
UK-Wales
UK-Scotland
UK-Northern Ireland
UK-England
Sweden
Spain
Slovenia
Slovakia
Romania
Portugal
Poland
Norway
Netherlands
Malta
Luxembourg
Lithuania
Latvia
Italy
Ireland
Iceland
Hungary
Greece
Germany
France
Finland
Estonia
Denmark
Czech Republic
Cyprus
Croatia
Bulgaria
Belgium
Austria
*Poor data representativeness
Alcohol hand rub consumption in acute care
hospitals, ECDC PPS 2011-2012
HAI PPS 4600 trained
Susan Hopkins lead, HP Agency & HP Scotland
HALT 2 PPS 1700 LTCFs staff trained.
Fidelma Fitzpatrick & Tracey Dillane,
HSE & HP Surveillance Centre
2013:
http://www.ecdc.europa.eu/en/
publications/Publications/infect
ion-control-core-
competencies.pdf
2014-15: TRICE-Implementation Strategy includes:
IC Course assessments
IC/HH WIKI : ESCMID SGs to be involved
Revisiting TRICE IC Resources
Awaiting clearance for:
ECDC-Funded SIGHT Project
Should be in Lancet ID (Zing et al)
Increasing Healthcare Delivery in the Community
Increasingly aged populations
Decreasing lengths of hospital stay: HAIs
presenting in the community
Increasing numbers of step-down from hospital and
hybrid (Step-Down/Residential) facilities
Issues
with definitions of names of facilities
Lack of surveillance, infection control standards,
guidelines and audit .
LOW PRIORITY IN MANY COUNTRIES
See: Moro et al, ICHE 2010; 31 (suppl. 1); 559-62 (IPSE WP7)
Cookson et al, J Hosp Infect 2013; 85: 45-53 (HALT 1)

Carl Suetens
ECDC
Championed HALT
Antoon Gijsens
DG SANCO
Bea Jans
HALT Lead
LTCF a late addition
Cookson et al, J Hosp Infect 2013; 85: 45-53.
HALT-1 & 2 Reports

Katrien Latour, Abstract No ECCMI-4351
http://www.ecdc.europa.eu/en/Pages/home.aspx
5
th
May 2014

Additional & increasing burden of AMR organisms
Main increases are in AMR organisms
MSSA continuing increases
MRSA increases 7.6%/Y then decreases 4.8%/Y <> 2005

Surgical Site Infections
(SSIs)
Korol et al, PLoS ONE 8(12): e83743. doi:10.1371/journal.pone.0083743
1) Challenging:
very rich literature
many study designs,
settings,
categorizations &
definitions

2) Despite this
they consistently
found associated
SSI risk factors

3) Risk Factors
relate to:
reduced fitness,
patient frailty,
surgery duration,
& complexity
BC: Body warming,
glucose control,
triclosan stitches?


Risk score gauged independent influence of each risk factor
New logistic regression approach of quantifying the influence of
different operative types on SSIs
Model used 181 894 operations for derivation, 181 146 for validation
SSIRS captured 89.7% of the validation population
Web based system available significantly better discrimination than NNIS
Basic Risk SSI Index
Also a simpler SSIRS index permits 30-day SSI risk bedside estimation
without computational aids
BC: Needs external validation. ECDC interested?
van Walraven C, Musselman R. PLoS ONE 2013;8:e67167
Owens et al, JAMA. 2014;311:709-716
Retrospective analysis: 284, 098 ambulatory surgical procedures
Databases of 1/3 US population in 8 dispersed USA states
Needed postsurgical acute care visits
General, orthopaedic, neuro, gynae, & urologic surgery
Length of stay less than 2 days
SSIs at 14days 3.09 /1000 ambulatory surgical procedures
30days 4.84 /1000 ambulatory surgical procedures
63.7% within 14 days of the surgery: limited risk factor analysis
93.2% needed inpatient treatment
Low relative to all causes but significant adverse events
The Post Discharge Surveillance
An Elephant in the Room!
http://en.wikipedia.org/wiki/Elephant
Difficult to compare studies as
differences in e.g.
Lengths of stay
Operative categories
Definitions of infections
Methods of data collection:
Re-admissions only!
Telephone or Patient or
Healthcare worker reporting
If staff/patients are trained
Lack detail so work can
be repeated

American Journal of Infection Control 41 (2013) 591-6
Journal of Hospital Infection 86 (2014) 127e132
American Journal of Infection Control 41 (2013) 549-53
Ann Intern Med. 2013;159:447-455.

Post Discharge Surveillance (PDS)
J Hospital Infect 2013; 84: 267
(& refs to two previous letters)
Disputes including English HPA (PHE) SSI system do not
bench mark PDS data
Brisbane group supported English HPA responding:
Until a valid & cost-effective solution PDS is found do
not bench mark.
Hospitals are required to undertake PDS, so the data can
be used for internal (i.e. local) quality improvement
Should not be required to submit PDS data for public
scrutiny or be penalized for not doing so.

Raschka et al, AJIC 2013;41: 773-7
19% less selected HAIs over 4 years
Cost avoidance of at least $9 million
80% in last two years!
(so enormous potential: useful to quote internationally)
Interesting methodology
Vancouver regional
Canadian Inf. control
programme
Standardized policies,
procedures, and initiatives
(including hand hygiene
campaign)
The Flos Extraordinary Anniversary of the Year

60 years since description
of DNAs structure
Watson, Crick,
(Franklin and Wilkins)
http://www.chemheritage.org/discover/online-resources/chemistry-in-history/themes/biomolecules/dna/watson-crick-wilkins-franklin.aspx
4) Typing & Tracking HAI Organisms

Medline database
searches with terms

Infection
&
Molecular Epidemiology

No papers/100K/year

Lancet Infect Dis 2014; 14: 34152


20 items added to 22 item STROBE checklist

Should advance the quality & transparency of
scientific reporting, with clear benefits for
evidence reviews & health-policy decision making
Lancet Infect Dis 2014; 14: 34152

Lancet Infect Dis 2014; 14: 34152

Educate users (STROME-ID) e.g. strengths and limitations
Clear objectives to ensure optimises patient care/safety
Interpretation needs detailed epidemiological data
Golden fleece TIMELY automatic appropriate simplified
discriminant data : (TATs not stated in many papers!)
Dialogue with reference laboratories and others with expertise in
this area to optimize its potential.
Consider accreditation requirements for Reference labs
National information considered
National funding ref Public Health aspects
Optimisation of NGS information for Infection Control Teams
See also :Humphries & Coleman Letter: http://dx.doi.org/10.1016/j.jhin.2013.05.002
Ehrlich & Post JAMA Internal Medicine 2013;173: 1406-06
Struelens and Brisse. Euro Surveill. 2013;18(4):pii=20386.
Editorial and several very useful papers in issue
also look at: Price et al, CID 2014;58:60918
Invited paper: interesting analysis of potential
MRSA
Melo-Christino et al, Lancet 2013;382:205 (20 July 2013)
vanA +MRSA strain in Europe from Portuguese patient
USA MRSA type (ST105, SCCmec type II: common
HAI strain in Portugal)
No epidemiological links to USA
vanA source may a wound VRE
Treatment progressing and no spread thus far


Emerged in Brazil following multiple vancomycin courses
No spread so far: died with GNR BSI
Related to community USA 300 strain: has bsa CA MRSA
operon
PVL negative
Perhaps element originated from a GRE in another patient
in the same room: patient also positive (late)
Transferable to other S aureus (WOW!!!!!)
Worrying : USA 300 clades common globally
Rossi et al, N Engl J Med 2014;370:1524-31
174 SA and MRSA of CC8 (including CA USA300) from 5 Continents
1957-2008
Phylogeny explored at 112 genetic housekeeping loci, AMR and
diverse mobile genetic elements
9 clades: 8 independent SCCmec acquisitions : started in mid-1970s.
88% carried plasmidic rep gene sequences (5 rep genes and eight rep
families)
Increasing and stable AMR (9 classes) during the evolution of several
lineages, including USA300. (Comment: check pedigree of different
strains.)
Diverse virulence determinants
Perhaps WILL become a multiple resistant MRSA?
(USA300 now a hospital MRSA)

Strommenger et al, J Antimicrob Chemother
2014; 69: 616622
4 new MRSA mecA/C negative from 3 ST types from
Scottish patients
Perhaps due to identified amino acid substitutions in
their endogenous PBPs 1, 2 & 3?
Not BORSA strains, as resistant to both oxacillin &
cefoxitin
Need for vigilance ref molecular MRSA assays &
possible new drug target resistance
MUST NOT ABANDON PHENOTYPIC TESTING
Xiaoliang et al, J Antimicrob Chemother 2014; 69: 594597
A 55-pound or greater Hog produces
at least 10 gallons of manure a day (!)
Manure spread on surrounding Iowan
fields
MRSA can be aerosolized from this
manure to human food or water
sources.
Carrel et al, Infect Control Hosp Epidemiol 2014;35(2):190-192
BetterPhoto.com
McKinnell et al, ICHE 2013; 34(: 161170
Often ignored in studies & national screening programmes
Systematic review 1966-2012: 23 papers: 39,497 patients
Few studies looked at >1 such extra nasal site!
ICU admission: detects ~1/3 more
Hospital admission: >6% MRSA incidence: extra 37%
<6% MRSA: extra 50%
Sole sites (supports various guidelines)
Oropharynx +21%: Rectum +20%:
Wounds +17% : (Axilla +7%)
Dont forget ~25% of new cases are first positive
at manipulated sites e.g. wounds and catheters
CDC EIP-ABCs sentinel laboratory-based MRSA case
finding identified MRSA cultures in 9 US metropolitan areas
from 2005 through 2011

Detailed risk factor analyses for HA- & CA-MRSA

In 2011 invasive MRSA infections (80 461) 31% lower than in
2005


Dantes et al, JAMA Intern Med. 2013;173(21):1970-1978.
Dantes et al, JAMA Intern Med. 2013;173(21):1970-1978.
CA MRSA Stable: epidemiology
incomplete e.g. home/LTCF
Interventions
Culture, Organisational &
Behavioural Aspects
Culture
Excellent reviews: De Bono et al, J Hosp Infect. 2014; 86:
1-6 and Borg, J Hosp Infect 2014; 86:161-68
Essential www site of Geert Hofstede
http://geerthofstede.com/dimensions-of-national-cultures
Hand Hygiene Studies
Utilizing Shared Accountability and Financial Incentives
Talbot et al, ICHE 2013; 34: 1129-1136
Positive deviance study: Marra et al, AJIC 2013;41:984-8
Real-time assessment practice using a Theoretical
Behavioural Domains Framework. Fuller et al, AJIC
2014;42:106-10
Hot Topics!
Universal MRSA Screening
Universal MRSA Decolonisation/Suppression
Hammers to crack walnuts?
See posts on:
http://haicontroversies.blogspot.com
&
NEJM Letters
English Universal MRSA Screening
1) NOW Audit: Fuller et, al PLoS ONE 8(9): e74219
Implementation of universal screening was poor
Admission Screening performed on:
Emergency admissions 61% (median 67.3%)
Electives 81% (median 59.4%)
Very low MRSA admission prevalence:
Emergencies 1%: Electives 0.6%
Inpatient MRSA prevalence 3.3% (6% for original model)



2) Modelling
Consultation underway suggesting stopping universal
screening
Universal Decolonisation/Suppression
A Horizontal Strategy
Lee et al, 2013 doi 10.11.36/bmjopen-2013-003126

Derde et al, Lancet Infect Dis
2014; 14: 3139
Huang et al, N Engl J Med 2013. DOI: 10.1056/NEJMoa1207290
First RCT
Universal Antiseptic Use Risks
(Horizontal Strategies)
At what rates of resistant organisms is it cost effective?
Mupirocin needed: how effective is it in reducing infections?
Increasing side effects?
How and how often used, rotate them?
What is best antiseptic to use e.g. octenidine?
Inactive chlorhexidine/soap formulations?
Increasing disinfectant/antiseptic resistance
Increased quantities used
Sumps of bacteria e.g. leaking abscesses, suppurating
tracheostomies

Universal Antiseptic Use Risks
(Horizontal Strategies)
Surveillance issues
Locally: short lengths of stay, not detect damaged
organisms
Nationally: no surveillance
Resistance cut-off agreements review?
Maillard et al, Microb. Drug Res., 2013
doi:10.1089/mdr.2013.0039
Morissey et al, PLoS One. 2014; 9: e86669.
doi:10.1371/journal.pone.0086669



Universal versus Targeted MRSA Screening?
Deeny et al, JHI 2013

More efficient use of resources

Less potential for resistance to antiseptics

J Hosp Infect 2013; 85: 33-44

Hand hygiene

Only 39 quasi-experimental & 4 cluster & 2 RCTs /8,148 studies
over 12 years
Insufficient studies to assess single interventions!
How can we design bundles?
No of bundle components was not associated with greater effect:
Include one or two interventions tripled compliance
Include >two produced doubling of compliance
Two bundles effective and Three studies of each:
Education, Reminders, Feedback: OR (pooled) : 1.45 (1.12, 1.94)
If add Administrative Support, & alcoholic handrubs :
OR (pooled): 1.82 (1.69-1.97)

Schweizer, et.al, Clinical Infectious Diseases 2014;58:24859
Rock et al, American Journal of Infection Control 41 (2013) 994-6
Conclusion: HH before donning nonsterile gloves does not decrease
already low bacterial counts on gloves. HH before donning nonsterile
gloves may be unnecessary?
Comment: Saves time: will HCWs confuse with sterile glove usage
especially when stressed?

Use of scents in training1/3 increase in compliance
Comment: Effectiveness for: different staff? Sustained?
In real workplace? Pavlovian approach ethical? Own life.

Birnbach et al J Hosp Infect 2013;85: 79-81.