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The start of another infection prevention learning curve: reducing healthcare-associated Gram-negative bloodstream infections

  • M.H. Wilcox
    Affiliations
    Microbiology Research and Development, Leeds Teaching Hospitals NHS Trust, Leeds, UK

    University of Leeds, Leeds, UK

    Public Health England, London, UK

    National Infection Prevention & Control, NHS Improvement, UK
    Search for articles by this author
      A decade ago, many believed that reducing meticillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs) by 50% was unachievable; in England the total declined by ∼90% from its peak [

      Public Health England. Healthcare associated infections (HCAI): guidance, data and analysis. Available at: https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis [last accessed October 2017].

      ]. Similar incredulity surrounded a target in England to decrease Clostridium difficile infections by 30%, and yet today these are ∼75% fewer [

      Public Health England. Healthcare associated infections (HCAI): guidance, data and analysis. Available at: https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis [last accessed October 2017].

      ]. These remarkable improvements are contrasted by an inexorable rise in Gram-negative (GN) BSIs; since 2012–13, Escherichia coli BSIs have increased by ∼25% in England (from ∼32,000 to ∼41,000 in 2016–17), and so now dwarf MRSA BSIs at their peak by a ratio of about 5:1, and today by almost 50:1 [

      Public Health England. Healthcare associated infections (HCAI): guidance, data and analysis. Available at: https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis [last accessed October 2017].

      ]. The increasing incidence of E. coli BSI is an international phenomenon. Between 2005 and 2014 in a stable cohort of 32 hospitals in central France, the incidences of E. coli BSI more than doubled for community-acquired (CA) cases aged >75 years, CABSIs of digestive origin in patients aged 60–74 years, healthcare-associated (HA) BSIs, and BSIs associated with extended-spectrum β-lactamase-producing strains [
      • van der Mee-Marquet N.L.
      • Blanc D.S.
      • Gbaguidi-Haore H.
      • Dos Santos Borges S.
      • Viboud Q.
      • Bertrand X.
      • et al.
      Marked increase in incidence for bloodstream infections due to Escherichia coli, a side effect of previous antibiotic therapy in the elderly.
      ]. Also, national surveillance data from Switzerland show significant increases in the incidence of BSIs caused by E. coli and non-E. coli Enterobacteriaceae (P < 0.001) between 2008 and 2014 [
      • Buetti N.
      • Atkinson A.
      • Marschall J.
      • Kronenberg A.
      Swiss Centre for Antibiotic Resistance (ANRESIS). Incidence of bloodstream infections: a nationwide surveillance of acute care hospitals in Switzerland 2008–2014.
      ]. Hence, the scale of the new National Health Service (NHS) ambition to reduce HA GNBSIs by 50% by 2021 in England is daunting [

      NHS Improvement. Preventing healthcare associated Gram-negative bacterial bloodstream infections. Available at: https://improvement.nhs.uk/resources/preventing-gram-negative-bloodstream-infections/ [last accessed October 2017].

      ].
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      References

      1. Public Health England. Healthcare associated infections (HCAI): guidance, data and analysis. Available at: https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis [last accessed October 2017].

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      • Response to ‘The start of another infection prevention learning curve: reducing healthcare-associated Gram-negative bloodstream infections’
        Journal of Hospital InfectionVol. 99Issue 4
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          We read with interest the recent article by Wilcox outlining the steep curve ahead in reducing healthcare-associated Gram-negative bloodstream infections (HA-GNBSIs) [1]. Increasing Gram-negative resistance, coupled with the paucity of new antimicrobial agents, is a significant concern shared by clinicians, infection prevention control (IPC) practitioners, and policy-makers alike. Although the increase in numbers of GNBSIs appears to be an international phenomenon, unlike some of our European counterparts, the proportion of E. coli BSIs in England that were multidrug resistant (MDR) remained static between 2012 and 2016, with 5% of isolates reported as MDR for each consecutive year during that period (defined as resistant to all third-generation cephalosporins, an aminoglycoside and a quinolone) [2].
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