When, however, the same debate is written down the arguments can be taken out of context and so be misleading. The middle ground between two polarized positions can be lost, and in a supremely important area such as cross-infection this can be dangerous. This article must not, therefore, be taken as definitive but rather as a contribution to a vitally important discussion about how best to run a cystic fibrosis CF service.
Segregation for this debate means cohort segregation or the clustering of people with CF either as in- or out-patients according to the bacteria that they carry. This is not the same thing as infection control. Cohort segregation may or may not be a part of the much more complex business of infection control but can never be the whole story.
The Danger of Cross Infections for Those Living With Cystic Fibrosis
A clinic could have infection control without segregation. It could do this by ensuring no contact between patients as a part of best practice infection control. Conversely, it would be possible to have segregation without infection control, if for example patients came to a Pseudomonas-only clinic but the doctors did not wash their hands.
The American guidelines for infection control in CF recommend strict infection control without cohort segregation while the UK prefers a combination of both and puts great emphasis on cohort segregation.
I will present two main arguments. First, that infection control is essential, complex, many faceted and far more important than cohort segregation. Second, that cohort segregation is an illusion. It is illogical, unrealistic, ignores the complexity of CF microbiology and is occasionally harmful.
Also, it can deflect attention from much more important issues of good infection control and is therefore not good for our patients. Of course it is. There have been a number of catastrophic outbreaks causing huge distress among patients and staff at a limited number of CF centres. When we look closer, however, the precise causes of these outbreaks is somewhat mysterious. In the first place they are surprisingly limited in time and space. The same, or apparently the same, strains of bacteria have caused a number of deaths over a short period in one clinic but seem to have been less of a problem elsewhere.
The same pattern was reported from a Burkholderia cepacia complex Bcc outbreak in Edinburgh. Following these outbreaks there has been a rush to blame the organism and by association the individuals who carry it. This reaction seems altogether too simplistic. Alternatively they are genuinely the same but other factors are involved and we are missing something. Of particular concern is the multiplicity of bacteria and viruses in a CF lung; this could mean that a combination of bacteria x with virus y can be disastrous when either alone is not.
Whatever is going on it seems to me to be much more complicated that one vicious strain jumping from patient to patient. This leads on to the question of how these outbreaks occur. If we accept that the same organism spreads from one person with CF to another, this could happen by direct contact between patients or indirect transmission via the environment or hospital staff. The segregationists like to blame a combination of the organism and the patient. Their argument seems to be that segregating people into a few groups by bacterial species will prevent all other routes of transmission.
This seems unbelievably simplistic and it ignores a number of facts. Segregation by organism might be sensible if there were only a few bacteria involved and they remained constant.
Sadly this is not the case. Clinicians receive laboratory results that mention the bacteria that are looked for and so get a false idea that CF microbiology is simple.
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Leaving aside the difficulties of identity and stability of the individual strains of Pseudomonas referred to above, the microbiology is horrendously complex. Even if this variety remained constant, and is seems pretty unlikely that it does, how do we separate people with CF into logical groups according to their sputum microbiology?
Do we segregate according to a single organism, as single strain or some combination of organisms and strains? Are interactions between micro-organisms important? Do host factors matter, so that some organisms may be bad in one person but gentle in another? There seems to be too much complexity and too much ignorance for simple answers. For segregation to be logical and feasible we should know what bacteria, fungi and viruses matter and which one two, three or 60 each person is carrying. We cannot do this. In the first place the best information is always out of date.
When someone with CF makes a booking for a clinic the sputum result refers to some day in the past. It may be within the last week but more often is 2—3 months previously and by the time the clinic happens it may be even longer. While in the chronic stable state the organisms may be the same, and so it may be reasonable to use out-of-date information for a routine visit, the microbiology may change at the time of a clinical deterioration.
The next problem is what should be sent to the laboratory.
Cross-infection at events
Many people with CF do not cough sputum and so throat or cough swabs are used. These may or may not be a good reflection of what is or will later be present in the lungs. Perhaps the biggest problem is that we do not know what really matters. The history of CF has been one of blaming different bacteria. Staphylococcus aureus was the first, there was then a brief period of concern about Haemophilus influenzae , followed by a long period in which P.
Recently, new bacteria have been isolated and the importance of each is still being worked out. In the future there will be more. Finally different strains of the same species behave differently. There's something for everyone on our forum. Head on over and start talking about the issues that matter to you! Whatever challenges you're facing, if you need someone to talk to try our scheme for connecting people with cystic fibrosis. There's loads of support available for people with cystic fibrosis and their families, from grants to help with benefits.
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