Too much of a good thing?

A hospital in the UK is removing alcohol gel dispensers at entrances to the building because of instances of homeless persons drinking the gel. The article reports that two deaths in London have been attributed to this. Gel dispensers will remain in other parts of the hospital.

New MRSA bill in Congress

The MRSA Infection Prevention and Patient Protection Act was recently introduced into both the US House of Representatives and Senate. The bill mandates testing for MRSA on admission and discharge from the ICU and other high risk units. We can only hope that CDC is able to influence the lawmakers by bringing MRSA into perspective. If not, the winners will be the companies who make the MRSA testing products. The losers will be hospital infection control programs, which are already overworked and underresourced, and the patients these programs serve.

More on clothing and infection control

Today's Cleveland Plain Dealer has an article on public reaction to a photo that recently appeared in the paper. The photo showed two women in scrubs and hair covers at a farmers market. I suspect that a few years ago the photo would have attracted little attention, but some readers were concerned that produce could become contaminated by hospital pathogens and others were concerned about carriage of organisms into the hospital. Both are low probability events, but the importance of this article is the public's awareness of hospital acquired infections.

Religion vs. infection control, part 2

Last month I blogged about a phlebotomist in the UK who was facing disciplinary action because she wore a crucifix while working. Today, British newspapers are reporting that she has resigned her position because she refused to comply with an order to remove it. She reports that she wore it under her clothes. If this is true, the claim that the crucifix represents an infection control risk is baseless, and such heavy handed treatment only serves to undermines infection control efforts.

WSJ Health Blog Goofs!

The Wall Street Journal Health Blog has now corrected its previous post on the AMA House of Delegates voting in favor of a ban on white coats. The official AMA response (on p. 15 of this document) was to refer the resolution to another committee for further study. As I stated in a previous posting, it would have been surprising for the AMA to pass the resolution given the AMA's generally conservative approach, coupled with the iconic status of the white coat for the profession. Nonetheless, I still believe it makes sense to hang up those germ-laden coats for good.

Wear a mask when performing lumbar punctures!

An Ohio newspaper reports that two women developed meningitis recently due to Streptococcus salivarius after undergoing spinal anesthesia by the same anesthesiologist. It was noted that the anesthesiologist did not wear a mask during the procedures. One of the women died. Such cases have been increasingly recognized over the last several years, and occur when the saliva of a healthcare worker performing a lumbar puncture for diagnostic or therapeutic purposes contaminates the spinal needle which is in direct communication with the CSF. This can easily occur if the operator is talking when performing the procedure. For this reason, CDC specifically recommended that masks be worn during such procedures in its latest guideline on isolation precautions (p. 69 of this document).

Potential new option for treating C. difficile

A small case series in Clinical Infectious Diseases describes four patients with severe refractory Clostridium difficile infection successfully treated with IV tigecycline. Three of the patients had failed standard therapy with metronidazole and vancomycin. This is potentially important given the rising incidence in C. difficile. Unfortunately, my experience with this antibiotic for other indications has been poor since most of my patients could not tolerate the severe nausea it causes.

H1N1 infected healthcare workers

CDC has released an analysis of healthcare workers who became infected with H1N1 influenza. You can read it here, but there is so much missing data that it is difficult to draw any conclusions.

The VA colonoscopy problem...

Thanks to Mike for keeping up with the blog over the past few days—I’ve been out of commission for a several reasons, including an ill-advised decision to finally take the exam for certification by the American Board of Medical Microbiology. Now I’m leaving the country for a couple weeks, so it will be Mike’s blog until early July.

When I return, I may address the brewing political overreaction to the VA colonoscopy mess. I have some personal experience here, being the epidemiologist at one of the VA’s that underwent surprise site visits by the Office of Inspector General (here is the report). In the meantime, I’ll just highlight what I think is the best quote I’ve read on this so far, from Philip Alcabes, associate professor of urban public health at Hunter College in New York City:

“To claim that an extra threat of transmitting blood-borne viruses pertains to the VA's colonoscopy clinics seems like showmanship. Since it isn't clear that any patients were actually infected by this equipment, the situation doesn't seem to warrant special rhetoric. It would be better to try to separate the political controversy from the actual health problem here."

Revenge of the gram-negatives!

A new report for the pharmaceutical industry states that the market for drugs to treat hospital-acquired gram-negative organisms will increase by $1 billion over the next 10 years. The report notes that the market for gram-positive drugs has been more lucrative, but now the opportunities for gram-positive drugs are declining. Let's hope that Pharma is successful in its quest for new gram-negative drugs given the worsening problems we are encountering with highly resistant gram-negative infections and few agents available currently for their treatment.

AMA calls for banning white coats

The Wall Street Journal Health Blog is reporting that the AMA House of Delegates voted today to recommend that hospitals ban white coats. Given the iconic stature of the white coat, I am quite surprised by the vote. Now a real debate will likely begin in the US on the topic. Click here to read more on why the white coat poses infectious risks.

USA300 invades a nursing home

A study in this month's Emerging Infectious Diseases analyzes the molecular epidemiology of MRSA infections over a 10 year period (1997-2006) at a 1,000 bed long-term care facility in San Francisco. Of the nearly 1,300 patients with S. aureus clinical isolates, 58% were methicillin resistant, with an increase to 72% methicillin resistance in 2006. Most notably, in 2002 11% of MRSA isolates were the USA300 clone with a sharp rise to 64% in 2006. The majority of USA300 strains were associated with skin/soft tissue infections. Given the high rates of transfer of patients between LTCFs and acute care hospitals, the implications of this study are very important, and we must be concerned with how widespread this problem is beyond the LTCF studied.

Note to surgeons: Double glove!

A study in this month's Archives of Surgery from Andreas Widmer's group at the University of Basel evaluated the risk of intraoperative glove perforation on the development of surgical site infection. The investigators found that perforation of gloves occurred in 16% of more than 4,000 procedures studied. For those procedures in which antimicrobial prophylaxis was not used, the adjusted odds ratio for development of surgical site infection following glove perforation was 4.2 (CI95 1.7-10.8, p 0.003). For cases in which antimicrobial prophylaxis was used, there was no difference in infection rates between cases where glove perforations occurred vs. those where no perforation occurred. The implication of this study is that double gloving should become a standard practice. In 2007, the American College of Surgeons recommended that double gloving should be performed to protect the surgeon from coming into contact with the patient's blood and body fluids. Now we know that double gloving will also protect the patient.

The short end of the just-in-time stick

This morning's Boston Globe has an article on problems with the medical supply chain unmasked by the H1N1 outbreak. Some of the difficulties relate to a just-in-time supply strategy, which was developed by the automotive industry and philosophically views inventory as waste. So when an outbreak of disease emerges abruptly, hospitals find themselves quickly exhausting supplies of masks, testing swabs, and medications. This is another example of the problems that occur when healthcare is fundamentally viewed as a commodity rather than as a public good.

Quote of the day

From Peter Ragusa, a new medical graduate from the University of Minnesota, in the Wall Street Journal Health Blog, on the resolution before the AMA House of Delegates to urge physicians to give up their white coats:

As with many things in medicine, just because we can’t prove it doesn’t mean it’s not true. It’s hard to do randomized double-blind controlled trials with something like this. But I’m a med student and I can look down at my sleeve and see it’s dirty, I can look down at my tie and see it’s dirty.

Stay calm, it’s only a PANdemIC

WHO finally called it, based upon widespread community transmission. In this time of global uncertainty, there are few things we can count on. Among them: more quotes from Dr. Michael Osterholm, and repeated references to prior pandemics that occurred in the pre-antibiotic or pre-antiviral eras.

On a related front, SHEA has drafted a position statement on control of the novel H1N1 in healthcare facilities, calling for the CDC to adopt guidance similar to that now adopted by WHO and by many state public health departments (we’ve touched in this before). A letter was sent today, along with the position statement, to the directors of CDC and OSHA.

When the treatment is worse than the disease

The University of Missouri Health Care System is re-evaluating its current policy on healthcare workers with latent tuberculous infection, which currently encourages but does not mandate treatment. The impetus for the review is a healthcare worker who had tested positive for latent tuberculosis via positive skin testing many years ago but declined to be treated, and recently developed active disease, exposing over 200 persons to tuberculosis. I suspect that most hospitals have similar policies and am not aware of a hospital that either prohibits those with latent but untreated infection from working or mandates treatment of latent tuberculosis. By definition, latent tuberculosis is not contagious but every person with latent infection has a small chance of developing active infection, which is contagious.

Isoniazid (INH), the standard drug used to treat latent tuberculosis given daily for nine months, is not an innocuous drug. In just the past few years, I have seen two deaths (both persons in their early 40s) and another healthy man who required a liver transplant due to the liver toxicity caused by the drug. Thus, I believe the drug is too toxic to require latently infected healthcare workers to be treated. Like the vast majority of healthcare workers, I have a TB skin test placed yearly. But I have decided that should my skin test convert to positive, I would not take INH because I believe it is too dangerous. We sorely need safer drugs for this condition. And we need better tests to detect latent tuberculosis--those currently available have many false positives and false negatives.

The plight of hospital infection programs: Doing more with less

APIC today released a survey of nearly 2,000 infection control practitioners that was conducted in March 2009. The results are alarming and serve to corroborate what many of us have suspected--resources for hospital infection prevention programs are declining.

Importantly, 41% of those surveyed reported reductions in staffing of infection prevention programs. This has resulted in reduction of infection surveillance by 24% of programs, reduction of process auditing by 20%, decreased environmental and walking rounds by 42%, and decreased educational programs by 38%.

Over half of those surveyed reported that regulatory requirements and reporting mandates make it harder for them to focus on infection prevention. Perhaps The Joint Commission and other regulatory bodies should think more about the adverse unintended consequences of their ever increasing mandates.

What's in a name?

In this morning's New York Times, Dr. Larry Altman discusses problems with usage of the term "pandemic." He notes that a "useful definiton is far more complicated and elusive than officials thought," and reference sources are contradictory and imprecise. As Dan questioned in previous posts here and here, does pandemic only involve how widespread the disease is geographically or does it also have implications for severity of illness? Help is apparently on the way, since Dr. Altman's piece points out that the Control of Communicable Diseases Manual, the bible for field epidemiologists, will contain a definition for pandemic.

Smallpox vaccine: Whatever happened to primum non nocere?

This morning's LA Times describes the sad case of Cory Belken, a 20 year old marine, who in January was given the smallpox vaccine while having undiagnosed acute leukemia. Two weeks after vaccination the diagnosis of leukemia was made and he underwent induction chemotherapy. Approximately 1 month later, he developed progressive vaccinia (details of his case along with photos have been published in the MMWR). Treating his progressive vaccinia has required nearly 300 vials of vaccinia immune globulin (a dosage that would typically treat 30 patients).

A military physician describes Lance Cpl. Belken as a victim of bad timing. Actually the young marine is a victim of bad policy. The last naturally occurring case of smallpox occurred over 30 years ago, and smallpox is the only infectious disease to have been eradicated. Because of fears that the virus could be used as an agent of bioterror, vaccination resumed in 2002 in the military. A campaign to vaccinate 400,000 civilians failed miserably, achieving 10% of its target. Our hospital was the first to refuse to vaccinate healthcare workers because we felt the live virus vaccine was too dangerous for our healthcare workers and because of the concern that a healthcare worker could potentially transmit the vaccine infection to a patient.

As of October 30, 2004, 822 adverse events associated with smallpox vaccination were reported. This resulted in 85 hospitalizations, 2 permanent disabilities, 10 life threatening illnesses and 3 deaths. And as the LA Times article demonstrates, the adverse events continue to occur.

Smallpox vaccine is the most dangerous vaccine in use today. Given the lack of any cases of smallpox anywhere in the world for the last 3 decades, the risks of this vaccine simply can't be justified.

Early lessons from H1N1

The Trust for America's Health, the Center for Biosecurity, and the Robert Wood Johnson Foundation have released a report analyzing lessons learned from the H1N1 response. The report is worth reading, and mostly confirms what those on the ground already know. For example, here are the 10 early lessons:

1. Investments in pandemic planning and stockpiling antiviral medications paid off;
2. Public health departments did not have enough resources to carry out plans;
3. Response plans must be adaptable and science-driven;
4. Providing clear, straightforward information to the public was essential for allaying fears and building trust;
5. School closings have major ramifications for students, parents and employers;
6. Sick leave and policies for limiting mass gatherings were also problematic;
7. Even with a mild outbreak, the health care delivery system was overwhelmed;
8. Communication between the public health system and health providers was not well coordinated;
9. WHO pandemic alert phases caused confusion; and
10. International coordination was more complicated than expected.

Unfortunately, it will be difficult to make necessary investments in public health infrastructure during this economic downturn (the recovery act funding is time-limited, so it’s difficult for public health departments to expand infrastructure and add personnel when they don’t know if future funding will be available).

The third bullet point, about “science-driven” response plans, is particularly applicable to the transmission route and mask issues we’ve blogged about before. I’m not sure if public health officials fully understand the impact on local hospitals and clinics of assuming airborne rather than droplet spread for influenza.

Washing away bad bugs

A new study in Critical Care Medicine documents the benefit of chlorhexidine bathing in ICU patients. The multicenter study performed in 6 ICUs compared a 6-month period of routine bathing with soap and water to a subsequent 6-month period of daily bathing with chlorhexidine. During both phases of the study, active surveillance cultures for MRSA and VRE were performed on admission to the ICUs and weekly thereafter. Acquisition of MRSA decreased by 32% and VRE acquisition decreased by 50% during the chlorhexidine phase. VRE bloodstream infections were reduced by 73%. There was no difference in the incidence of MRSA bloodstream infections between the two study periods, but the rate was very low in both phases of the study. This is a great example of a non-pathogen specific, simple but effective, horizontal intervention to prevent healthcare associated infections.

Movin' up to phase 6?

Despite an expressed desire to incorporate a severity measure into their pandemic alert system, WHO might soon move to phase 6 (out of 6). Meanwhile, the C.D.C. reports that pneumonia and influenza mortality in their 122 city surveillance remains below the epidemic threshold.

Maybe the new WHO pandemic alert system should keep the 6 phases, applied regardless of disease severity, and then when phase 6 is reached and the disease is very severe, they could jump right to eleven.

Bare below the elbows: Coming to a hospital near you?

It's encouraging and even surprising that the AMA is considering a resolution to encourage a bare below the elbows approach in US hospitals. Unfortunately, it's unlikely to pass. There's never been an organization more symbolically linked to the white coat than the AMA. Most hospital epidemiologists in the US seem to be unable to connect the dots between contact precautions and bare below the elbow, generally endorsing the former but not the latter. The paradox, of course, is that both interventions are based on undisputed findings that clothing can become contaminated and the assumption that contaminated clothing may serve as a fomite. But between those two dots is a lot of magical thinking about the white coat. Given the UK's success in reducing MRSA and C. difficile, part of which may be due to bare below the elbows, and the public's interest in healthcare associated infections, I would predict that five years from now scrubs will be de rigueur.

AMA to weigh in on hospital dress codes

Mike has blogged about this, and has gone to great lengths to encourage a “bare below the elbows” approach to patient care at VCU—but so far I haven’t seen a major professional society or public health authority in the U.S. make any definitive statements. So I find it very interesting that the AMA will be considering a resolution later this month (at their House of Delegates meeting in Chicago on June 13-17) that squarely addresses the role of clothing and accessories (jewelry, wrist watches, etc.) in the spread of pathogens in hospitals. All the resolutions can be accessed here (this one is resolution 720)—since I can’t directly link to it I’ll copy the text below. As you can see, the AMA doesn’t get very prescriptive about what should be done, just advises that hospitals adopt dress codes that “minimize transmission of nosocomial infections, particularly in critical and intensive care units.” But they specifically refer to the UK “bare below the elbows” policy, so I think it leaves the door open for hospitals to begin changing policy in this area….I’ll let Mike weigh in on just how difficult that can be.

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 720 (A-09)
Introduced by: Medical Student Section
Subject: Hospital Dress Codes for the Reduction of Nosocomial Transmission of Disease
Referred to: Reference Committee G

Whereas, Nosocomial infection is a significant cause of morbidity and mortality in the US; and
Whereas, According to the Centers for Disease Control and Prevention, approximately 1.7 million hospital patients contracted nosocomial infections in 2002, resulting in nearly 100,000 deaths; and
Whereas, Patients in critical or intensive care units are most susceptible to nosocomial infection, accounting for nearly 25 percent of all cases; and
Whereas, Neckties, long sleeves, and other clothing items and accessories have been implicated in the spread of nosocomial infection; and
Whereas, In 2007, the British National Health System implemented a “bare below the elbow” hospital dress code, banning neckties, long sleeves, hand and wrist jewelry, and traditional physician white coats; therefore be it
RESOLVED, That our American Medical Association advocate for the adoption of hospital guidelines for dress codes that minimize transmission of nosocomial infections, particularly in critical and intensive care units. (Directive to Take Action)