Journal roundup: Ebola, antibiotic use and abuse, and the usual suspects.

Ebola

Ebola continues to make waves in the general and specialist journals, with high-profile publications including clinical details from a large cohort of cases in Sierra Leone confirming a case fatality rate of 74%; controversies over quarantine, personal protective equipment, and whether the scale of preparedness in developed healthcare systems matches the risk; laboratory safety; the social and humanitarian impact in West Africa; epidemiology, including stark World Health Organization projections of thousands of new cases per week in West Africa; transmission dynamics; and promising vaccine trials.9, 10

Antibiotic use and abuse

‘European Antibiotic Awareness Day’ and the roughly corresponding US ‘Get Smart About Antibiotics Week’ are impressive, coordinated strategies. It is difficult to find the right metric to measure their success, but there is some evidence from Europe that public understanding of antibiotics is gradually improving. The recent World Health Assembly resolution on antimicrobial resistance will help.

JAMA recently published a special issue on infectious diseases with a number of antibiotic-related articles. An impressive cluster randomized controlled trial compared the impact of selective oral decontamination and selective digestive decontamination (SDD) in a multi-centre Dutch intensive care unit (ICU) study. SDD was associated with lower levels of gastrointestinal carriage of antibiotic-resistant Gram-negative bacteria and ICU-acquired bacteraemia, but more pronounced increases in aminoglycoside-resistant Gram-negative bacteria. Can we afford to give antibiotics indiscriminately to this high-risk group?

A multi-state collection of point prevalence surveys of antibiotic use in the USA published in JAMA found that almost exactly 50% of patients were on antibiotics. This rate is considerably higher than the rate found in a point prevalence survey in Europe (35%). Furthermore, at least 5% of patients in the US survey were on antibiotics for no good reason.

Meanwhile, commentary in the New England Journal of Medicine discussed the problems, progress and prospects of antibiotic resistance. The article outlines the need for recognition of the problem, incentivizing the development of new agents, and a move from cure towards prevention, leadership and stewardship. However, an article in the Journal of Antimicrobial Chemotherapy highlighted the stark reality of the antibiotic problem in some parts of the world, with approximately one-third of community prescribers in Spain admitting to dispensing antibiotics without prescription. It is likely that the real figure is considerably greater.

The usual suspects

Recently, a few articles have contributed to the ongoing debate about whether a universal or targeted approach to infection prevention should be adopted. The implementation of antimicrobial surfaces is a promising universal approach, and a recent study published in the American Journal of Infection Control found that a quaternary ammonium organosilane product reduced the average bacterial count on ICU surfaces by approximately 2-logs for eight weeks after application. However, chitosan-impregnated scrubs did not fare so well, with no significant reduction in bacterial contamination compared with untreated controls.

One of the commonly cited reasons for moving away from contact precautions for patients infected or colonized with meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) is that patients under contact precautions have an increased rate of adverse events. However, a study published in the Journal of Hospital Infection found that abandoning contact precautions for patients with MRSA and VRE did not affect the rate of adverse events. This may suggest that the increased rate of adverse events for patients under contact precautions has more to do with their underlying risk factors than with contact precautions per se.

As the threat of multi-drug-resistant Gram-negative bacteria continues to unfold, it is encouraging to see a success story reported from Italy, where a regional intervention reversed the trend in carbapenem-resistant Klebsiella pneumoniae. However, a disturbing study, also from Italy, reported a high rate (43%) of colistin resistance in carbapenem-resistant K. pneumoniae across the country. Fortunately, only 1% of these isolates were pan-drug resistant, but the trend is of concern. Finally, an outbreak of New Delhi metallo-beta-lactamase-1 Enterobacteriaceae associated with contaminated duodenoscopes highlighted the need for appropriate decontamination, and perhaps even sterilization, of duodenoscopes.24, 25

Conferences

ID Week took place in Philadelphia, USA in early October. Conference themes included the global outbreak threats from Ebola and Middle East Respiratory Syndrome (MERS); the importance of improving surveillance of healthcare-associated and community-associated infection, including the need to embrace new technology; updates of Clostridium difficile treatment and epidemiology, with a strong focus on the impressive impact of faecal microbiota transplantation; improving cleaning and disinfection using education and training or supplemental use of automated room decontamination technologies; and future issues for infection prevention and control, principally the move away from contact precautions for MRSA and VRE, and the urgent need for antibiotic stewardship.

The biannual Healthcare Infection Society (HIS) Conference took place in Lyon, France in mid November. Conference trends included updates on C. difficile, norovirus and other pathogens associated with healthcare-associated infection, coverage of the options for dealing with the contaminated healthcare environment, and the need for education and communication to turn the rising tide of antibiotic resistance. A special edition of the Journal of Hospital Infection dedicated to the HIS Conference will be published in 2015.

And finally…

Dealing with contaminated surfaces is a challenge, and a study from Italian and Belgian researchers proposed the novel solution of deliberately seeding hospital surfaces with Bacillus spp. spores to reduce the ecological space for contamination with pathogens. It remains to be seen whether or not this will catch on.

Conflict of interest statement

None declared.

Funding sources

None.