Stewardship, stewardship, and more stewardship!

That’s what you’ll find when you read the April issue of ICHE. The entire issue is dedicated to antimicrobial stewardship, and includes several excellent articles. So consider it your Spring Break reading.

There’s even an article from Eli’s old stomping ground, describing what happens when you take an effective antimicrobial stewardship program and flush it (spoiler alert: turns out to be a bad idea). Lest we forget, the Maryland group is still the only one to demonstrate, in a randomized controlled trial, the effectiveness of adding computerized clinical decision support for stewardship efforts. So go back and read that paper too, while you’re at it.

I’ll end with this quote from our friends Arjun Srinivasan and Neil Fishman, from the intro to the special issue:

There has perhaps never been a more critical juncture for antimicrobial stewardship. There is growing interest from key stakeholders—clinicians, healthcare administrators, and policy makers—and a growing body of evidence demonstrating the benefits of stewardship. We now need to harness the interest and the science to move toward making stewardship programs an integral part of all healthcare facilities. Education and messaging will play an important role. For too long, our message on the benefits of stewardship has been too narrowly focused on reducing costs and potentially reducing antibiotic resistance. The former is not compelling to most clinicians, and the latter, while generally accepted, has been difficult to demonstrate clearly since the emergence and spread of resistance is so complicated and multifactorial. Moving forward, we need to emphasize that antibiotic stewardship is, fundamentally, a critical patient safety and public health issue for all healthcare settings that can improve the quality of care.

Photo: Alexander Fleming, from Wikimedia Commons

I'm madder than a giraffe with a sore throat...

…over the CDC budget, which Eli blogged about last week. As their budget gets cut further and further, the CDC leans more heavily on the Prevention and Public Health Fund (“Prevention Fund”) to pay for core functions. The problem is that the Prevention Fund was originally designed to fund new initiatives, not to fill in for ill-advised core budget cuts. And since the fund was established as part of the Affordable Care Act, it has now become a political target (and was already cut drastically as part of the payroll tax cut extension and Medicare “doc fix” deal). If you require further evidence of the tenuous status of the Prevention Fund, know that it has been termed “an Obamacare slush fund” by the GOP (note to whoever came up with that genius terminology: you are a colossal ***).

Ezra Klein had a great post last month about why prevention funding is so vulnerable in the current climate. In it he quoted Rick Mayes from the University of Richmond, on the “prevention paradox”:

“If public health measures are effective, the problems they are aimed at are often solved or never even materialize, thereby making them virtually invisible.

Few individuals have personal interactions with or know what epidemiologists, health program coordinators, virology trainers, and outreach specialists do. When individuals are spared from a disease because the air in their office building is clean, it is not immediately clear whom to thank or if thanks are even necessary. As a consequence, public health professionals, programs, and policies are largely invisible to the public and taken for granted.”

I agree with this, but I think the issue is even larger, and more depressing. The statement above assumes that if people were just informed of the consequences of not supporting prevention efforts, they would act differently. I don’t think so. I’m hearing more political candidates question the basic social contract, the very assumption that government has a legitimate role in providing for the common good (and that we all have an obligation to pay for it). I encourage you to listen to this podcast, entitled, “What Kind of Country”, which details some trade-offs that local governments are making when money runs out and citizens are no longer interested in paying to provide for the common good. I was particularly struck by the story of individual citizens refusing a small tax increase to keep all the streetlights on in their town, but willing to pay $300 out of pocket to keep the lights near their own house burning.

Submit your work to IDWeek!

Although the abstract deadline for IDWeek is still 2 months away, it is not too early to decide what work you wish to submit for presentation in San Diego in October. The abstract submission site is open until May 11, 2012 for regular submissions and until August 10, 2012 for late breakers.

(More) Other Advice to Young Epidemiologists

1) Don't call anyone an idiot.
2) Question subjects carefully.



For "other advice" see ICHE 2006

How to have your influenza vaccine and get the flu too!

We just had our first confirmed case of influenza in Lake Wobegon, out here on the edge of the prairie. At the VA at least.  Helen Branswell of the Canadian Press has a great article in the Winnipeg Free Press today exploring the reasons why we might be having such a late and mild flu season.  Possible reasons include a mild winter and perhaps high vaccine uptake.

Branswell quotes one of our favorite Canadian's Allison McGeer who said "there's lots of evidence that it's not as simple as temperature. People have been looking for temperature and humidity indications for a long time — and there may well be some contribution — but if it is, it's subtle and complex. It's very clear that it's not just having a milder than usual winter that makes a difference."  The article also mentions that vaccination rates in Canada and the United States are around 35-40%, which should not be high enough to explain the magnitude of annual influenza epidemics. Of course vaccination rates are only relevant if the vaccine is effective.

In the most recent issue of Archives of Internal Medicine, Kenny Wong and colleagues from the University of Toronto studied the effectiveness of influenza vaccination in a large cohort of community-dwelling Ontario residents over 65yo. Using administrative data from 2000 to 2009 and controlling for selection bias using an instrumental variable approach, they report minimal effectiveness in reducing all-cause mortality. Looking at a composite outcome of mortality plus admissions for pneumonia, they did find vaccine to be protective. For an excellent review of this paper, prior studies and the use of instrumental variables, see this most excellent post by Robert Roos over at CIDRAP. The summary of all of this is: with current vaccines, those over 65 can have their shot and get the flu too.

Sources:
1) Wong K, et al. Arch Intern Med. 27 Feb 2012
2) Branswell H, Winnipeg Free Press. 6 Mar 2012
3) Roos R, CIDRAP. 1 Mar 2012

Turn that Code Brown upside down!

Because it’s Clostridium difficile prevention day! The CDC just issued a new Vital Signs report on C. difficile (MMWR details here), Cliff “C-diff” McDonald has a blog post up at Safe Healthcare, a podcast can be found here, and an updated CDC webpage on C. difficile is here.

The CDC media telebriefing took place at noon ET today, and we are already beginning to see the news media responding. One main message can be illustrated via Figure 1 from the MMWR report, below. The rest you can read for yourself.

British Olympics Handshake Kerfuffle

Dr. Ian McCurdie, the British Olympic Association's chief medical officer warned his athletes to avoid handshakes this summer or they might pick up germs, according to a recent AP story. In response the Department of Health said: "It goes without saying that we should all wash our hands regularly to keep them clean and prevent spreading bugs, but there's no reason why people shouldn't shake hands at the Olympics." The best take on this probably came via Twitter when Olympic champion rower Zac Purchase said it's a "bit pointless unless u r going to run around with disinfectant 4 every surface you come into contact with."

This is serious business.  In 2008, Great Britain came in 4th in overall medal count, a scant 26 medals behind Russia.  From what I can tell, the only thing that held them back was a spike in transient infections!

We've posted on this sort of thing before where a study last year found the risk was 0.019 bacterial pathogens acquired per handshake during a commencement; although, it's viruses that we most worry about. Of course, if you don't want to shake someone's hand there are other greeting options:

3/7 Update:  Another nice opinion is available here, and the ban has officially been lifted.

Religion vs infection control: issue #6

Here's a new and very sad case to add to our series on the intersection of religion and infection control. A few days ago, The New York Daily News reported that an infant died in a Brooklyn hospital due to disseminated herpes simplex virus type I infection. The virus was transmitted to the baby via a practice, metzitzah b'peh, performed by some mohels following circumcision whereby the mohel uses his mouth to suck blood from the wound. In a related piece, a rabbi and mohel in the Broward-Palm Beach New Times blog, provides details on how the procedure can be performed safely while still fulfilling Talmudic requirements. Several other cases of neonatal herpes infection (see full text paper from Pediatrics here) and at least one death have been previously reported. Additional information from the New York City Health Department can be viewed here.

Graphic:  The ceremony of Brit-Milah by Herman Gold.

Can you tell a hospital is safe by its "broken windows"?

This past weekend there were many discussions of James Q. Wilson's "broken windows" theory. Dr. Wilson, unfortunately, passed away this past week. The theory and research suggest that perception of a safe neighborhood prevents crime. If people feel they're in a safe place, they are less likely to commit a crime. If, however, they feel the neighborhood is unsafe or crime-ridden, they're more likely to commit crime. Thus, under this theory, police forces should arrest and prosecute even the smallest crimes, such as graffiti, and cities should quickly repair broken windows.

I lived in Rudy Giuliani's New York City during the implementation of this strategy, but I'm not here to defend his law enforcement policies one way or another, since I'm not an expert. Crime did fall, but it might have been for other reasons.  What I'm more interested in is if there could be an analogous theory in hospitals?  Is there a safe hospital theory?  It made me wonder if clinicians in safer or cleaner hospitals are more apt to practice hand hygiene or have higher compliance with CLABSI checklists.

I'm not aware of much data in this regard.  Two of the better analyses were done by Pat Stone's group at Columbia (I was a co-author). Looking at data from 415 ICUs in 250 hospitals they found that there was no convincing evidence of a cross-over effect between CLABSI and VAP; that is compliance with the CALBSI Bundle elements was never associated with a decrease in VAP rates.  In a separate paper, they found that compliance with the VAP bundle did not lower CLABSI rates. So for at least two device infections, there appears to be no such thing as a safe hospital. Lankford et al. in EID (2003) hypothesized that hand hygiene would increase after construction of a shiny new hospital. It actually decreased from 53% to 23%.  Hopefully Mike and Dan can add to this list of studies.

There has been a lot more research on what makes a quality hospital outside of infection prevention.  Twenty years ago, there was an important study in Medical Care that looked at disease-specific mortality in acute myocardial infarction, congestive heart failure, pneumonia, stroke, obstructive lung disease, or gastrointestinal hemorrhage in 30 hospitals. They found little correlation between disease-specific mortality rates within each hospital. So, MI mortality was not correlated with CHF mortality, even if they were likely to be treated by the same physicians and nurses. If mortality isn't a quality indicator, one wonders if other quality indicators have any relevance.

And what is a post without a non-scientific anecdote? Several years ago, when I was the hospital epidemiologist at a large hospital in Baltimore, we had high rates of MDR-Acinetobacter infections. This led our group to conduct a pilot study looking at the impact of universal gown and gloves in ICU-settings. At the time a new Chief Medical Officer, who happened to be a pulmonary-critical care specialist, started attending in our ICUs. He was struck at the level of gown/glove compliance that he saw and declared that he had never seen such a safe hospital. This actually meant something, since he had just moved from Barnes Jewish Hospital in St. Louis; home to one of my heroes, Vicki Fraser.  Were we really safer than BJH? I don't know, but the sight of all of those gowns and gloves did make it appear that we were really trying our best to be safe. Soon after, our CLABSI rates fell drastically, after a lot of effort sure, but the culture was changing. Maybe there is something in this theory that applies to hospitals after all? Too bad there appears to be no such thing as a "safe" hospital.