Abstract Introduction Guidelines on antimicrobial therapy are subject to periodic revision to anticipate changes in the epidemiology of antimicrobial resistance and new scientific knowledge. Changing a policy to a broader spectrum has important consequences on both the individual patient level (e.g. effectiveness, toxicity) and population level (e.g. emerging resistance, costs). By combining both clinical data evaluation and an ethical analysis, we aim to propose a comprehensive framework to guide antibiotic policy dilemmas. Methods A preliminary framework for decision-making on antimicrobial policy was constructed based on existing literature and panel discussions. Antibiotic policy themes were translated into specific elements that were fitted into this framework. The adapted framework was evaluated in two moral deliberation groups. The moral deliberation sessions were analysed using ATLAS.ti statistical software to categorize arguments and evaluate completeness of the final framework. Results The final framework outlines the process of data evaluation, ethical deliberation and decision-making. The first phase is a factual data exploration. In the second phase, perspectives are weighed and the policy of moral preference is formulated. Judgments are made on three levels: the individual patient, the patient population and society. In the final phase, feasibility, implementation and re-evaluation are addressed. Conclusions The proposed framework facilitates decision-making on antibiotic policy by structuring existing data, identifying knowledge gaps, explicating ethical considerations and balancing interests of the individual and current and future generations.

BackgroundIsolation precautions are applied to control the risk of transmission of multi-drug resistant organisms (MDROs). These precautions have been associated with adverse effects, such as anxiety and depression. This study aimed to quantify stigma among MDRO carriers and its association with perceived mental health and experienced quality of care.MethodsA quantitative questionnaire study was performed in MDRO carriers exposed to ≥3 days of isolation precautions during hospitalization. Items derived from the Consumer Quality Index questionnaire (CQI) were used to assess perception of care. Stigma scores were calculated using the recently modified Berger Stigma Scale for meticillin-resistant Staphylococcus aureus (MRSA). Mental health was measured with the RAND Mental Health Inventory. The Spearman rank correlation test was used to assess the association between stigma score and RAND mental health score.FindingsOf the 41 included carriers, 31 (75.6%) completed both questionnaires. The experienced quality of care was ‘good’ according to CQI score. Twenty-four percent reported not to have received proper explanation about MDRO carriership from healthcare workers (HCWs). MDRO-associated stigma was reported in 1/31 (3.2%). Poor mental health was self-reported in 3/31 (9.7%). There was no correlation between stigma score and RAND mental health score (Spearman correlation coefficient: 0.347).ConclusionsIn this study, MDRO carriers exposed to ≥3 days of isolation precautions did not report stigma. This contrasts with a recent study that investigated MRSA-associated stigma and may be explained by contact plus airborne isolation protocols in MRSA compared with contact isolation alone in most other MDROs. Also, the psychological impact may be of a different magnitude due to as yet unknown reasons.

Dutch healthcare institutions are relatively successful in preventing outbreaks of antibiotic-resistant pathogens, thus protecting vulnerable patients. However, measures taken to prevent the introduction and spread of MDROs can be burdensome for asymptomatic carriers of such bacteria or for people who may have been exposed to them. This leads to ethical dilemmas. On the basis of a study of the impact of being a carrier and precautionary measures on carrier well-being, we present an ethical framework for responsible care for carriers. We argue that solidarity requires that the burden of prevention and control of resistance is to be shouldered by society as a whole. It is not right to see this problem primarily as a conflict between the protection of vulnerable patients on the one hand and carriers on the other.

Nederlandse zorginstellingen slagen er relatief goed in om uitbraken van antibioticaresistente pathogenen te voorkomen, en daarmee kwetsbare patienten te beschermen. De voorzorgsmaatregelen die daarvoor worden genomen, kunnen echter belastend zijn voor asymptomatische dragers van zo’n bacterie of voor mensen die er mogelijk mee in aanraking zijn gekomen. Dit leidt tot ethische dilemma’s. Op basis van een studie naar de impact van dragerschap en voorzorgsmaatregelen op het welzijn van dragers presenteren we een ethisch kader voor verantwoorde zorg bij dragerschap. We betogen daarbij dat uit oogpunt van solidariteit de lasten voor preventie en bestrijding van resistentie zoveel mogelijk maatschappelijk gedragen moeten worden. Het is niet terecht om het probleem primair te beschouwen als een conflict tussen bescherming van kwetsbare patienten enerzijds, en dragers anderzijds.

AbstractMany countries have implemented specific control measures directed at carriers of multidrug-resistant organisms (MDRO) in order to prevent further introduction and transmission of resistant organisms into hospitals and other healthcare related settings. These control measures may in many ways affect the lives and well-being of carriers of MDRO, resulting in complex ethical dilemmas that often remain largely implicit in practice. In this chapter, we propose to conceptualize the impact of MDRO control measures on the well-being of individual carriers in terms of capabilities and functionings. A capabilitarian framework for the ethical treatment of MDRO carriers commits us to conceptualize the harm done to carriers in terms of the impact that MDRO control measures have on what they are able to do or be. Adopting and adapting Nussbaum’s list of ten central human capabilities, we present a taxonomy of capabilities and functionings that are normatively relevant for the design and evaluation of MDRO control measures.

Objectives: A comprehensive overview of the ways control measures directed at carriers of multidrugresistant organisms (MDRO) affect daily life of carriers is lacking. In this systematic literature review, we sought to explore how carriers experience being a carrier and how they experience being subjected to control measures by looking at the impact on basic capabilities. Methods: We searched Medline, Embase and PsychINFO until 26 May 2016 for studies addressing experiences of MDRO carriers. Twenty-seven studies were included, addressing experiences with methicillin-resistant Staphylococcus aureus (n = 21), ESBL (n = 1), multiple MDRO (n = 4) and other (n = 1, not specified). We categorized reported experiences according to Nussbaum's capability approach. Results: Carriage and control measures were found to interfere with quality of care, cause negative emotions, limit interactions with loved ones, cause stigmatization, limit recreational activities and create financial and professional insecurity. Further, carriers have difficulties with full comprehension of the problem of antimicrobial resistance, thus affecting six out of ten basic capabilities. Conclusions: Applying Nussbaum's capability approach visualizes an array of unintended consequences of control measures. Carriers experience stigmatization, especially in healthcare settings, and have limited understanding of their situation and the complexities of antimicrobial resistance. (c) 2018 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Many countries have implemented infection control measures directed at carriers of multidrug-resistant organisms. To explore the ethical implications of these measures, we analyzed 227 consultations about multidrug resistance and compared them with the literature on communicable disease in general. We found that control measures aimed at carriers have a range of negative implications. Although moral dilemmas seem similar to those encountered while implementing control measures for other infectious diseases, 4 distinct features stand out for carriage of multidrug-resistant organisms: carriage presents itself as a state of being; carriage has limited relevance for the health of the carrier; carriage has little relevance outside healthcare settings; and antimicrobial resistance is a slowly evolving threat on which individual carriers have limited effect. These features are of ethical relevance because they influence the way we traditionally think about infectious disease control and urge us to pay more attention to the personal experience of the individual carrier.

Typing techniques are laboratory methods used in outbreak management to investigate the degree to which microbes found within an outbreak are related. Knowledge about relational patterns between microbes benefits outbreak management, but inevitably also tells us something about the relational patterns of the people hosting them. Since the technique is often used without explicit consent of all individuals involved, this may raise ethical questions. The aim of this study was to unravel the complex ethical deliberation of professionals over the use of such techniques. We organised group discussions (n = 3) with Dutch outbreak managers (n = 23). The topic list was based on previously identified ethical issues and discussions were analysed for recurrent themes. We found that outbreak managers first and foremost reflect on the balance of individual harm with public health benefit. This key question was approached by way of discussing four more specific ethical themes: (1) justification of governmental intervention, (2) responsibility to prevent infections, (3) scientific uncertainty and (4) legal consequences. The themes found in this study, rephrased into accessible questions, represent the shared ethical understanding of professionals and can help to articulate the ethical dimensions of using molecular science in response to infectious disease outbreaks.

Typing techniques are laboratory methods used in outbreak management to investigate the degree to which microbes found within an outbreak are related. Knowledge about relational patterns between microbes benefits outbreak management, but inevitably also tells us something about the relational patterns of the people hosting them. Since the technique is often used without explicit consent of all individuals involved, this may raise ethical questions. The aim of this study was to unravel the complex ethical deliberation of professionals over the use of such techniques. We organised group discussions (n = 3) with Dutch outbreak managers (n = 23). The topic list was based on previously identified ethical issues and discussions were analysed for recurrent themes. We found that outbreak managers first and foremost reflect on the balance of individual harm with public health benefit. This key question was approached by way of discussing four more specific ethical themes: (1) justification of governmental intervention, (2) responsibility to prevent infections, (3) scientific uncertainty and (4) legal consequences. The themes found in this study, rephrased into accessible questions, represent the shared ethical understanding of professionals and can help to articulate the ethical dimensions of using molecular science in response to infectious disease outbreaks.

Background: Many countries have implemented guidelines to prevent transmission of meticillin-resistant Staphylococcus aureus (MRSA). Important contextual factors of stigma can be identified in the context of MRSA. Over the past decade, concerns have been raised over a possible stigmatizing effect of these actions.Aim: To identify and quantify the occurrence of MRSA-associated stigma, and to explore its association with mental health in a country with an MRSA 'search and destroy' policy.Methods: In 2014, a questionnaire study among 57 Dutch MRSA carriers (people that carry MRSA without signs of MRSA infection) was performed. Stigma was measured with an adjusted version of the Berger HIV Stigma Scale. Mental health was measured with the five-item RAND Mental Health Inquiry.Findings: Thirty-two (56%) MRSA carriers reported stigma; of these, eight (14%) reported 'clear stigma' (Berger score >110) and 24 (42%) reported 'suggestive for stigma' (Berger score 76-110). Educational level, female sex and intensive MRSA eradication therapy were associated with higher stigma scores. Poor mental health (RAND score <60) was reported by 33% of MRSA carriers. Stigma and mental health scores were inversely correlated. Stigma was experienced most frequently in healthcare settings, and was seldom experienced in the religious community or at sport facilities.Conclusion: A substantial proportion of MRSA carriers reported stigma due to MRSA, and stigma was associated with poor mental health. Anticipation of MRSA-associated stigma is warranted, both in the way that care is delivered by hospital staff and in the way that care is organized within the hospital. (C) 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

The growing popularity of social networking sites (SNS) and its increasing accessibility due to the advent of new technologies (such as smartphones and tablets, enabling users to be online more frequently) provide public health agencies with new opportunities for health promotion, prevention, disease control and research. However, the use of SNS by public health agencies raises ethical concerns. Mandeville et al. addressed a number of these concerns by means of an interesting case of contact tracing through Facebook around a patient with meningococcal septicaemia (Mandeville et al., 2013). Although the described situation is especially complicated due to the patient's incapability to provide informed consent, the unexpected interference of a proactive contact and the use of the patients' public Facebook 'wall', it clearly outlines the ethical issues surrounding the use of social media for contact tracing. Fortunately, most situations are less complex in daily practice of communicable disease control. SNS are here to stay. Although methods on how to use SNS most effectively in public health are understudied, evidence is growing that strategies including SNS can be more effective than traditional communication methods (Bennett and Glasgow, 2009; Gold et al., 2011; Bauermeister et al., 2012; Thackeray et al., 2012). In the area of communicable disease control, particularly for sexually transmitted infections, there are ample examples where SNS and Internet, in general, proved to be valuable tools for surveillance (Ginsberg et al., 2009; Signorini et al., 2011), reaching and involving target populations (Bull et al., 2004; Young, 2013; Young et al., 2013), or for learning more about (risk) perceptions and behaviors within these populations (Love et al., 2013).

In dit onderzoek wordt een serie van 9 vragen gepresenteerd die gebruikt kunnen worden om de besluitvorming rondom het gebruik van moleculaire typeringstechniek voor de bron- en contactopsporing te structureren. De vragen zelf leiden niet tot een keuze, maar moeten worden gezien als een instrument dat het besluitvormingsproces structureert. De set vragen is bedoeld voor professionals werkzaam bij GGD, RIVM of medisch microbiologisch laboratoria.

Using polymerase chain reaction (PCR) to detect faecal hepatitis A virus (HAV) can be a useful tool for investigating HAV outbreaks, especially in low-endemic countries. We describe the use of faecal HAV PCR as a non-invasive tool for screening. Two Dutch children visiting different daycare centres were diagnosed with hepatitis A in 2011. A systematic contact investigation was started in the daycare centres and relevant contacts were screened. The faecal HAV PCR test was used to screen the children. The employees were screened with a serum IgM. The faecal HAV PCR test proved to be an appropriate tool for screening. The screening of a total of 135 children and employees in the daycare centres resulted in evidence of eight asymptomatic infections and transmission to three related daycare centres. Control measures were taken including immunization. Compared to an epidemiological investigation without screening, 144 extra contacts were vaccinated based on the screening results. This most likely led to improved prevention of expansion of the outbreak.

Nederland telt bijna 20.000 geregistreerde hiv-patienten. De huidige hiv-preventie is gebaseerd op de promotie van condoomgebruik en een actief testbeleid, maar deze strategie leidt niet bij alle doelgroepen tot het terugdringen van de hiv-epidemie. In juli 2012 werd tenofovir/emtricitabine (TDF/FTC) goedgekeurd voor langdurig gebruik door de Amerikaanse Food and Drug Administration (FDA) als pre-expositieprofylaxe (PrEP) bij groepen met frequente onveilige risicocontacten. Bij een dagelijkse inname en goede therapietrouw kan TDF/FTC effectief zijn als PrEP en worden weinig bijwerkingen gerapporteerd. Nadelen van het gebruik van TDF/FTC als PrEP zijn het potentiele risico op ontwikkeling van virale resistentie en op verminderd condoomgebruik, de relatief hoge kosten en de benodigde intensieve counseling. In uitzonderlijke situaties kan langdurig gebruik van PrEP van toegevoegde waarde zijn op het huidige hiv-preventiebeleid in Nederland. Naar de praktische haalbaarheid en beschermende effectiviteit van het ad-hocgebruik van PrEP voorafgaand aan een risicocontact moet verder onderzoek gedaan worden.

In de lente van 2012 wordt de GGD Fryslân op de hoogte gesteld van een bofi nfectie bij een zesjarige jongen, die met een hersenvliesontsteking is opgenomen in het ziekenhuis. De jongen zit in groep drie van de lokale basisschool. De basisschool is de enige school in het dorp en heeft een gereformeerde grondslag. Omwille van religieuze overwegingen is de jongen niet gevaccineerd, evenals zijn broer en zussen die op dezelfde school zitten. De vaccinatiegraad op de school is laag (vermoedelijk minder dan 50%). De GGD wil de ouders van de medeleerlingen graag informeren over de bofi nfectie, maar de schooldirecteur wil zijn medewerking niet verlenen. Wat te doen?

Current thinking on the development of molecular microbial characterisation techniques in public health focuses mainly on operational issues that need to be resolved before incorporation into daily practice can take place. Notwithstanding the importance of these operational challenges, it is also essential to formulate conditions under which such microbial characterisation methods can be used from an ethical perspective. The potential ability of molecular techniques to show relational patterns between individuals with more certainty brings a new sense of urgency to already difficult ethical issues associated with privacy, consent and a moral obligation to avoid spreading a disease. It is therefore important that professionals reflect on the ethical implications of using these techniques in outbreak management, in order to be able to formulate the conditions under which they may be applied in public health practice.