If your hands and wrists are not bare, if your nails aren't short and tidy, you can't wash your hands properly. We all learn this when we first go to the operating room and are introduced to the ritual of "scrubbing".

Well, it is time to bring the scrub to the wards. It's simple. We'll all take off our dirty white coats, roll up our sleeves, leave our rings and watches at home and scrub. Nothing fancy, no complicated rules about who has MRSA or VRE or C. difficile or ESBL, just good clean hands.

Here is a bit of foreshadowing of messaging for an upcoming campaign to encourage attention to simple measures to prevent infections.

and

An excellent television ad produced by the UK Department of Health encouraging good hygiene in an effort to limit H1N1 influenza transmission.

This graph depicts total outpatient antibiotic use in Canadian provinces expressed in DDD/1000 inhabitant-days. The information was obtained by the Canadian Integrated Program for Antibiotic Resistance Surveillance (CIPARS) from IMS Health Canada. CIPARS utilized the World Health Organization's Anatomical Therapeutic Chemical Classification and Defined Daily Dose methodology.

There are extremely large differences between provinces. Newfoundland and Labrador has, by far, the highest overall rate of consumption at approximately 30 DDD/1000 inhabitant-days. This corresponds to about 1.2 prescriptions per person per year.

I gave a talk at the Canadian Society for Laboratory Science annual general meeting today concerning antibiotic resistance. In it I suggested that everyone has a role in the solution to the problem. Afterward someone asked me if they should question their physician more thoroughly when they are given a prescription. It is something I have been asked before and have generally been reluctant to suggest that questioning their doctor's prescription decision was appropriate. I have been very conscious of the need for a cooperative, blameless approach.

I have changed my mind.

Everyone should demand very specific information about all antibiotic prescriptions. You should be aware of the exact diagnosis, the expected course of illness and symptoms that would suggest need for further medical assessment. Discussions of alternatives are completely appropriate. If your doctor can't or won't give you the information you want consider another opinion.

Taking antibiotics is serious business and deserves serious personal consideration. The more questions asked the better.

We physicians have an obligation to be ecologists. Our collective actions are having measurable effects on the evolution of the microorganisms that live with us and occasionally infect us. Have a read of this paper I wrote with Dr. David Patrick of the BC CDC to see how you can be part of the solution to this ever-escalating problem.

Click here to check it out.

An excellent paper and accompanying editorial in today's Canadian Medical Association Journal describes huge increases in fluoroquinolone antibiotic resistance in Ontario from 2002 to 2006. Similar changes have been described in many other parts of the world.

Fluoroquinolones have only been in existence since the 1980s and first licensed for sale in Canada in 1988. They were the first new class of antibiotic introduced for many years and were received with extreme expectations. They were widely touted as the solution to antibiotic resistance to penicillins, tetracyclines, sulfa antibiotics and others.

Everybody pees. Urinals are poorly designed. Pee ends up on shoes and pants and floors.

Someone in the Netherlands tackled this problem and designed a urinal that efficiently catches pee and uses a clever bit of psychology to help the boys leave the maximum amount of pee in the urinal. A fake fly is etched on the porcelain in precisely the right spot.

By the time it is realized that the fly doesn't move the pee is collected - simply brilliant.

One patient, one room, one bed, one sink goes the infection control rhyme. That was until a Pseudomonas aeruginosa outbreak between December 2004 and March 2006 at Toronto General Hospital killed 12 transplant patients.

The issue: tall, high pressure 'gooseneck' sinks drove water straight into the drain hole of the sink without getting water into the basin.

The problem: sludge in the bottom of the sink containing Pseudomonas aeruginosa was splashed out of the drain when the high pressure water hit it and transported around the room when people washed their hands.

The solution: Who knows best on this one? The doctor? The Infection Control Practitioner? The epidemiologist? The engineer?

The answer is likely all of the above.

First things first

Design is important and needs to be first. Before cost, before space, before time, before everything else, things need to be designed and evaluated. Things seem to get designed these days to fill a space, or fit along a wall, or to be this tall by this wide, and once the right ratio of tall-ness to wide-ness is achieved, the evaluation is over.

Design is how it works, not how it looks.

via the Globe and Mail

The current infection control mantra advocating actively seeking out the humans harboring antibiotic resistant bacteria and "decolonizing" them with antibiotics is fabulously flawed and shortsighted. More antibiotics will certainly not be a fix for the complex problem of antibiotic resistance.

There will always be bacteria circulating in human populations. Staphylococcus aureus, Streptococcus pyogenes and Streptococcus pneumoniae have been living in and on humans since the inception of humanity. When a new or "re-circulated" type (strain) enters a population, as is happening now with so-called community-associated MRSA (USA type 300 or Canadian type CMRSA 10), some people will become ill with relatively minor illness. An unfortunate few will have serious illness. Many more will become immune without illness. The strain will spread widely and over time will appear to be less virulent (able to cause disease) as the immunity of the population increases. It will be transmitted less efficiently as there will be fewer people with overt disease and fewer susceptible individuals. Another strain will emerge that has an advantage and the complex story will write its next chapter.

Antibiotic resistance is rapidly escalating and is a threat to us all. It is the "global warming" of medicine and just as energy consumption will necessarily continue, so will consumption of antibiotics. Resistance to antibiotics can't be completely "fixed" but must be actively managed - forever. As antibiotic consumption cannot be optimized by market distribution active regulatory control is the only option.

At present there are many uncoordinated levels of regulation of drug distribution in Canada. Federally, a new drug must be approved for sale by Therapeutic Products Directorate (TPD). Once approved (given a "notice of compliance" with regulations) a manufacturer can market the drug to prescribers however the central marketing effort is directed toward large governmental and third party payers. The vast majority of human drugs in Canada are payed for by these institutional drug plans. Each province and territory has their own drug plan and their are several large private plans that provide coverage to employees of private companies, unions members, government employees, and some individuals. The provincial drug plans vary widely in structure, eligibility, coverage, administration and means and levels of cost sharing.