D. Jenkins

Meticillin-resistant Staphylococcus aureus (MRSA) in hospitals and the community: model predictions based on the UK situation

Theoretical modelling has shown that patient movements in and out of hospitals are likely to affect nosocomial transmission dynamics considerably. The community acts as a reservoir and readmission of individuals colonised during previous admissions can result in sporadic transmission episodes within hospitals. We investigated patient movement patterns and frequency of readmissions using seven years of complete data from the University Hospitals of Leicester NHS Trust. Sufficient information is held on individual patients to study the heterogeneity in readmission. Overall, we found that an infected person has a 44.2% chance of being readmitted to the Trust while still infected. This value is far higher than previous estimates (3.7% [Cooper et al., Health Technol Assess 2003;7(39)]), highlighting the potential importance of transmission driven by hospital admissions. For this reason we believe consideration of readmissions from the community population to be critical to the success of hospital acquired infection control.

The impact of the introduction of fidaxomicin on the management of Clostridium difficile infection in seven NHS secondary care hospitals in England: a series of local service evaluations

Clostridium difficile infection (CDI) is associated with high mortality. Reducing incidence is a priority for patients, clinicians, the National Health Service (NHS) and Public Health England alike. In June 2012, fidaxomicin (FDX) was launched for the treatment of adults with CDI. The objective of this evaluation was to collect robust real-world data to understand the effectiveness of FDX in routine practice. In seven hospitals introducing FDX between July 2012 and July 2013, data were collected retrospectively from medical records on CDI episodes occurring 12xa0months before/after the introduction of FDX. All hospitalised patients aged ≥18xa0years with primary CDI (diarrhoea with presence of toxin A/B without a previous CDI in the previous 3xa0months) were included. Recurrence was defined as in-patient diarrhoea re-emergence requiring treatment any time within 3xa0months after the first episode. Each hospital had a different protocol for the use of FDX. In hospitals A and B, where FDX was used first line for all primary and recurrent episodes, the recurrence rate reduced from 10.6xa0% to 3.1xa0% and from 16.3xa0% to 3.1xa0%, with a significant difference in 28-day mortality from 18.2xa0% to 3.1xa0% (pu2009<u20090.05) and 17.3xa0% to 6.3xa0% (pu2009<u20090.05) for hospitals A and B, respectively. In hospitals using FDX in selected patients only, the changes in recurrence rates and mortality were less marked. The pattern of adoption of FDX appears to affect its impact on CDI outcome, with maximum reduction in recurrence and all-cause mortality where it is used as first-line treatment.

Screening strategies in surveillance and control of methicillin-resistant Staphylococcus aureus (MRSA)

With reports of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) continuing to increase and therapeutic options decrease, infection control methods are of increasing importance. Here we investigate the relationship between surveillance and infection control. Surveillance plays two roles with respect to control: it allows detection of infected/colonized individuals necessary for their removal from the general population, and it allows quantification of control success. We develop a stochastic model of MRSA transmission dynamics exploring the effects of two screening strategies in an epidemic setting: random and on admission. We consider both hospital and community populations and include control and surveillance in a single framework. Random screening was more efficient at hospital surveillance and allowed nosocomial control, which also prevented epidemic behaviour in the community. Therefore, random screening was the more effective control strategy for both the hospital and community populations in this setting. Surveillance strategies have significant impact on both ascertainment of infection prevalence and its control.

Guidance on the use of respiratory and facial protection equipment

n Summaryn n Infectious micro-organisms may be transmitted by a variety of routes, and some may be spread by more than one route. Respiratory and facial protection is required for those organisms that are usually transmitted via the droplet/airborne route, or when airborne particles have been artificially created, such as during ‘aerosol-generating procedures’. A range of personal protective equipment that provides different degrees of facial and respiratory protection is available. It is apparent from the recent experiences with severe acute respiratory syndrome and pandemic (H1N1) 2009 influenza that healthcare workers may have difficulty in choosing the correct type of facial and respiratory protection in any given clinical situation. To address this issue, the Scientific Development Committee of the Healthcare Infection Society established a short-life working group to develop guidance. The guidance is based upon a review of the literature, which is published separately, and expert consensus.n n

Successful treatment of meticillin-resistant Staphylococcus aureus bacteraemia in a neonate using daptomycin.

Daptomycin is licensed for the management of Staphylococcus aureus infections in adults, including those caused by meticillin-resistant S. aureus (MRSA). Few data exist on paediatric use or dose guidance in neonates. We report the case of a neonate with MRSA bacteraemia successfully managed with daptomycin. Dose requirements were substantially higher than those recommended for adults.

Respiratory and facial protection: a critical review of recent literature

n Summaryn n Infectious micro-organisms may be transmitted by a variety of routes. This is dependent on the particular pathogen and includes bloodborne, droplet, airborne, and contact transmission. Some micro-organisms are spread by more than one route. Respiratory and facial protection is required for those organisms which are usually transmitted via the droplet and/or airborne routes or when airborne particles have been created during ‘aerosol-generating procedures’. This article presents a critical review of the recently published literature in this area that was undertaken by Health Protection Scotland and the Healthcare Infection Society and which informed the development of guidance on the use of respiratory and facial protection equipment by healthcare workers.n n

Extracorporeal membrane oxygenation and severe acute respiratory distress secondary to Legionella: 10 year experience.

Legionella-associated respiratory failure has a high mortality, despite modern ventilation modalities. Extracorporeal membrane oxygenation (ECMO) is used to achieve gas exchange independent of pulmonary function in patients with severe respiratory failure. This was a retrospective review of the management and outcome of patients with Legionella-associated respiratory failure treated with ECMO support in a large ECMO center over the past 10 years. A retrospective review of patients with confirmed Legionella-associated severe respiratory failure managed with ECMO support at a single center. Between 2000 and 2010, 19 patients with severe respiratory failure caused by Legionella were managed with ECMO after failure to respond to conventional intensive care management. Median PaO2/FiO2 ratio was 66 and median pCO2 was 60 torr. Sixteen patients (84%) survived to hospital discharge. Extracorporeal membrane oxygenation should be considered in patients with Legionella-associated respiratory failure, who have failed conventional ventilation.

Highlighting clinical needs in Clostridium difficile infection : the views of European healthcare professionals at the front line

BACKGROUNDnClostridium difficile infection (CDI) is the leading cause of infectious nosocomial diarrhoea in Europe. Despite increased focus, its incidence and severity are increasing in many European countries.nnnAIMnWe developed a series of consensus statements to identify unmet clinical needs in the recognition and management of CDI.nnnMETHODSnA consortium of European experts prepared a series of 29 statements representing their collective views on the diagnosis and management of CDI in Europe. The statements were grouped into the following six broad themes: diagnosis; definitions of severity; treatment failure, recurrence and its consequences; infection prevention and control interventions; education and antimicrobial stewardship; and National CDI clinical guidance and policy. These statements were reviewed using questionnaires by 1047 clinicians involved in managing CDI, who indicated their level of agreement with each statement.nnnFINDINGSnLevels of agreement exceeded the 66% threshold for consensus for 27 out of 29 statements (93.1%), indicating strong support. Variance between countries and specialties was analysed and showed strong alignment with the overall consensus scores.nnnCONCLUSIONnBased on the consensus scores of the respondent group, recommendations are suggested for the further development of CDI services in order to reduce transmission and recurrence and to ensure that appropriate diagnosis and treatment strategies are applied across all healthcare settings.

A survey of attitudes towards methicillin-resistant Staphylococcus aureus bacteraemias amongst United Kingdom microbiologists

OBJECTIVESnMethicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs) in the UK are common and associated with significant morbidity and mortality. Vancomycin is the usual first-line therapy. However, vancomycin treatment of BSIs due to MRSA strains with vancomycin MICs of 1-2 mg/L is successful in <10% of cases. No consensus exists on when to use newer agents, particularly when vancomycin MICs are >1 mg/L. We therefore surveyed UK practices of the management of MRSA BSIs due to isolates with increased vancomycin MICs.nnnMETHODSnFive hundred and seventy-one UK consultant microbiologists were contacted via e-mail and asked to take part in an online survey, hosted at www.surveymonkey.com. Responses were collated by the website, downloaded and analysed in a Microsoft Excel (Microsoft Corporation) spreadsheet.nnnRESULTSnOne hundred and eight respondents participated in the survey. Only 32.7% routinely measure MICs, mostly by Etest. Forty-two percent use vancomycin alone for removable-focus infections, whilst for infections of cardiac or orthopaedic origin, 49% would add rifampicin. Few respondents use daptomycin, linezolid or tigecycline empirically. Sixty-nine percent would use linezolid as a second-line agent, with only 19% opting for daptomycin. For an isolate with a vancomycin MIC of 4 mg/L, respondents would use daptomycin (81%) or linezolid (91%) in patients with a poor clinical response.nnnCONCLUSIONSnVancomycin is the mainstay therapy for MRSA BSIs, even when MICs are not measured or raised, despite evidence of high failure rates. The use of newer agents frequently does not follow European or US licensed indications, may be inappropriate and may result in avoidable deaths.

Balancing the risks to individual and society: A systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals

BACKGROUNDnAntimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals.nnnAIMnTo provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use.nnnMETHODSnA systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship.nnnFINDINGSnThe risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services.nnnCONCLUSIONSnWhen tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice.