The document discusses various challenges related to managing multidrug-resistant organisms (MDROs) such as VRE in healthcare settings. It notes an outbreak of VRE and lists actions requested of healthcare workers, but also acknowledges ongoing issues like hand hygiene compliance and misunderstandings around isolation protocols. While advanced infection control techniques are desirable, the document emphasizes that proper implementation of basics like hand hygiene, isolation, cleaning, and adherence to guidelines are most important. It raises questions around whether all MDROs require equal screening and management efforts. Regional coordination on surveillance, guidelines and personnel is presented as a strategy to improve practices across different care settings.

1. 28-­‐03-­‐15
1

2. 28-­‐03-­‐15
2
a
smart
man
once
said
…
¤
Basics
are
the
new
black
¤
MDRO
–
are
they
all
equal?
¤
Regional
efforts
¤
PercepHons
(InfecHon
Control
vs
Clinicians)
¤
Less
is
more!
(Guidelines)
¤
Help
-­‐
by
design
and
by
paHents
The
case:
¤
You
have
an
outbreak
of
VRE
¤
The
OMT
(including
CEO)
asks
all
HCWS
to:
²
Be
compliant
with
HH
and
dressing
code
²
Admit
paHents
according
to
“flag”
²
Correctly
use
contact
isolaHons
measures
²
Ensure
good
environmental
cleaning
X

3. 28-­‐03-­‐15
3
²
We
sHll
need
to
work
on
HH
and
behaviour
²
Even
simple
organizaHonal
things
don’t
happen
²
Contact
isolaHons
–
how,
when,
why???
²
No
money,
no
clue,
no
plan,
no
cleaning
¤
…
while
we
dream
of
advanced
infecHon
control,
…
the
truth
is
that
we
have
to
teach
the
basics,
over
&
over
&
over
&
….
¤
Hand
hygiene
¤
Personal
hygiene
¤
IsolaHon
measures
¤
Environmental
cleaning
¤
Just
do
what
you
have
been
asked
to
do
¤
Basics
are
the
new
black
¤
MDRO
–
are
they
all
equal?
¤
Regional
efforts
¤
PercepHons
(InfecHon
Control
vs
Clinicians)
¤
Less
is
more!
(Guidelines)
¤
Help
-­‐
by
design
and
paHents
¤
MRSA
¤
ESBL
¤
MDR-­‐AB
¤
All
other
MDROs
¤
VRE
¤
CRE
¤
PRP
e.g.
Cip
+
Genta
R
ESCO

4. 28-­‐03-­‐15
4
¤
All
paHents
at
risk
for
MDRO
carriage
need
to
be
screened
and
isolated
on
admission!
(idenHcal
criteria
to
MRSA
Search
&
Destroy
policy)
²
Yes,
do
it
(and
like
it)
¤
All
contacts
of
“unexpected”
MDRO
paHents
needs
to
be
screened
²
10%
of
all
paHents
are
ESBL
carriers
and
2-­‐4%
carry
VRE
à
do
I
really
have
to
do
the
same
follow
up
for
all
MDRO
paHents/in
all
parts
of
the
hospital?
²
is
VRE
=
CRE
Ukley
et
al.
Lancet
1988;57-­‐58
Did
anyone
check
Guinness
for
VRE?
The
following
pictures
may
contain
shocking
details
on
infecHon
control
in
The
Netherlands
that
completele
contradict
their
good
reputaHon

5. 28-­‐03-­‐15
5
¤
Roomservice
¤
Roomservice-­‐plus
¤
Registered
nurse
¤
Nurse
asistant
¤
Cleaning
VRE
should
not
be
seen
as
an
An;bio;c
Resistance
Threat
but
as
an
indicator
of
a
failing
preven;ve
system
E.
coli
K.
pneumonia
Freeman
et
al.
AnHmicrob
Resistance
Infect
Control
2014;3:5
Freeman
et
al.
AnHmicrobial
Resistance
and
InfecHon
Control
2014,
3:5
Rooms
of
paHents
with
ESBL-­‐KP
have
substanHally
higher
contaminaHon
rates
than
those
with
ESBL-­‐EC.
This
finding
may
help
explain
the
apparently
higher
transmissibility
of
ESBL-­‐KP
in
the
hospital
serng

6. 28-­‐03-­‐15
6
Boring
Remarkable
In
deep
sh..
COLI
KLEBSIELLA
¤
Basics
are
the
new
black
¤
MDRO
–
are
they
all
equal?
¤
Regional
efforts
¤
PercepHons
(InfecHon
Control
vs
Clinicians)
¤
Less
is
more!
(Guidelines)
¤
Help
-­‐
by
design
and
paHents
¤
Implement
idenHcal
guidelines
in
a
region
²
exchange
of
personnel
²
paHent’s
expectaHons
¤
Combine
knowledge
&
experHze
¤
Share
surveillance
data
²
on
HAI’s
and
MDRO
incidences
¤
Include
all
regional
healthcare
serngs
²
from
GP
to
nursing
homes
and
specialized
clinics
integrated
MMB,
AMS
and
IC
service
¤
Basics
are
the
new
black
¤
MDRO
–
are
they
all
equal?
¤
Regional
efforts
¤
Percep;ons
(Infec;on
Control
vs
Clinicians)
¤
Less
is
more!
(Guidelines)
¤
Help
-­‐
by
design
and
paHents

7. 28-­‐03-­‐15
7
Policing
One-­‐track
mind
Guidelines
Guidelines
Guidelines
Guidelines
More
guidelines
…
&
more
ESBL
CRE
MRSA
MDR-­‐AB
XDR-­‐TB
PRP
MERS-­‐Cov
C.dif
Noro
Flu
Please,
no
more!

8. 28-­‐03-­‐15
8
IC
needs
to
be
to-­‐the-­‐point
….
may
not
always
be
true,
but
it
is
with
guidelines
MRSA
ESBL
C.dif
&
Co
CRE
…..
HAI
-­‐
prevenHon
CommunicaHon

9. 28-­‐03-­‐15
9
Almost
Good,
MD
• Education
• System change
• Motivation
…
but
was
shown
not
to
be
sufficient
to
bring
the
message
across
Nothing
new!
We
are
late
¤ PresenHng
something
new
and
improved
does
not
automaHcally
change
bahavior
!
¤ ‘The
lesson
from
markeHng
is
that
people
are
more
willing
to
change
their
behaviour
when
they
feel
good,
flakered,
challenged
powerful,
sexy
or
proud,
than
when
they
are
flooded
with
facts’
(Hodgkin
1999)
Onya,
the
Redskins
cheerer
(who
asked
that
her
last
name
be
withheld,
ciHng
team
policy),
has
her
picture
on
the
team's
Web
site
in
her
official
bikini-­‐
like
uniform
and
also
reclining
in
an
actual
bikini.
Onya,
27,
who
declined
to
idenHfy
the
company
she
works
for,
is
but
one
of
several
drug
representa;ves
who
have
cheered
for
the
Redskins

10. 28-­‐03-­‐15
10
Asch
conformity
experiments
¤ We
shouldn’t
be
the
“weatherman”
¤ An
innocent
associaHon
with
either
bad
or
good
things
will
influence
how
people
feel
about
us
or
a
product
² The
good
looking
models
next
to
the
car
² RaHng
of
idenHcal
car
changed
with
and
without
model
² Men
didn’t
believe
that
their
judgment
was
influenced
Liking
www.sciencexpress.org
/
20
November
2008
/
Page
1
/
10.1126/science.1161405
§
Orderly
alley:
33%
likering
§
GraffiH
alley:
§
69%
likering
¤ when
people
observe
inappropriate
behavior,
this
weakens
their
concern
for
appropriateness
§
Orderly
alley
§
No
graffiH
sign
§
Flyer
on
handlebar
§
avoid
likering
We
need
“order”
in
our
hospitals
and
people
showing
appropriate
behavior
!

11. 28-­‐03-­‐15
11
¤
Key
HCWs
(MDs,
RNs,
helpers,
cleaners,
…)
needs
to
be
associated
with
good
infecHon
control
pracHces
¤
Praise
instead
of
criHcs
¤
We
need
beker
role
models
¤ Start
iCare
campaigne
¤
Basics
are
the
new
black
¤
MDRO
–
are
they
all
equal?
¤
Regional
efforts
¤
PercepHons
(InfecHon
Control
vs
Clinicians)
¤
Less
is
more!
(Guidelines)
¤
Help
-­‐
by
design
Make
things
…
¤
IntuiHve
¤
TempHng
²
in
air
projecHng
¤
Safe
¤
Force
¤
Rewarding
Scheithauer
et
al.
BMC
InfecHous
Diseases
2013,
13:367
IntervenHons
were
aimed
at
increasing
compliance
as
well
as
reducing
the
number
of
HR
needed
by
improving
workflow
prac;ces.
Kramer
et
al.
BMC
Infect
Dis
2006;6:130
E.
coli
1.5h
to
6
months
Klebsiella
spp.
2.0h
to
>30
months
…
and
this
kind
of
cleaning
lady
is
hard
to
get

12. 28-­‐03-­‐15
12
¤
Indicators
(incidence
of
MDRO
from
BCs)
as
part
of
quarterly
management
rapport
and
public
reporHng
(2nd
gen
surveillance)
¤
IntegraHon
of
MMB/ID/AMS/IC
at
regional
levels
¤
A-­‐teams
(anHmicrobial
stewardship)
in
Hosp
&
NH
¤
Remote
video
assisted
behavior
change
(audits)
¤
Nanotechnology
for
surfaces
¤
New
ways
of
decolonizaHon
(microbiome)
¤
Virtual
reality/serious
gaming…
for
HCWs
training
¤
Robots/avatars
for
paHents
assist
Train
and
improve
the
basics
(including
HH)
MDRO
–
pick
your
fight
and
just
do
it!
Reduce
your
guidelines
Help
via
design
&
PaHent
involvement
Improve
communicaHon
(use
behavioral
science)
Work
locally,
but
think
regional
www.ARICjournal.com