They write comments!

Barry Farr and Bill Jarvis have responded to my post about their letter in ICHE! The most important thing about this is that it shows someone is actually reading this blog (hooray!). Their response is very long, but I encourage you to go read it in its entirety, in the comment section. It’s a barn burner!

I’ll try to focus my response on the main themes of their comment:

The claim that I demand randomized controlled trials (RCTs) is a straw man. I called for “well-designed, controlled trials.” Farr and Jarvis are correct that RCTs are expensive and can be difficult to adapt to some infection control questions. But there are many study designs other than RCTs that qualify as well-designed controlled trials! The study by Harbarth et al is perhaps the best example of a well-designed controlled trial of active surveillance and contact precautions. It is in fact the largest such study ever performed. Check it out. To demonstrate my objectivity, I am also linking to the study by Huang et al, which I believe to be the strongest published evidence supporting active surveillance for MRSA.

I won’t dignify the criticisms of the NIH-funded RCT of active surveillance with a detailed response. That study isn’t published yet! When it is, we’ll have plenty of time to debate the methods and the findings. The fact that some people began criticizing this study pre-emptively says more about their data-proof fervor for active surveillance than it does about the study.

The entire last half of their comment proves my point about poorly conceived, poorly designed studies of active surveillance. The last paragraph of my post was (I thought!) an obviously tongue-in-cheek parody of the kind of study Farr or Jarvis might cite to support active surveillance, if the numbers were reversed. Of course it is wrong to claim that the difference in publicly reported BSI rates at U.Va. and MCV is related to their respective approaches to MRSA control! And Farr and Jarvis needn’t convince me that U. Va. is a wonderful hospital—I'm proud to say that I did my residency training there, I'd be happy to receive care there (provided I'm shown to be MRSA-free), or to work there (OK, maybe that last part is out of the question now...).

It’s quite simple: (1) the data to support use of active surveillance/contact precautions to reduce morbidity and mortality from MDROs, in the absence of an outbreak, remain inconclusive, and (2) the burden of proof is on those who wish to force hospitals to adopt this approach to the control of MRSA.

Our professional societies (SHEA and APIC) have already weighed in: we shouldn’t be mandating active surveillance.