Friday, July 31, 2009

VAP: Do you know it when you see it?

Ask any infection control nurse, infectious diseases physician, or intensivist and they will tell you of the difficulty in trying to define and diagnose ventilator-associated pneumonia (VAP). This is because there are a number of other conditions that can mimic VAP. A new study in the Journal of Critical Care compares three VAP definitions to autopsy findings in 253 patients to determine the utility of the definitions. The CDC definition was not used, but is similar to one of the definitions applied in the study. None of the definitions performed well. The most sensitive definition (65%) had a specificity of 36%. On the other hand, one definition had a nearly perfect specificity (99%), but its sensitivity was dismal at 5%. The results of this study coupled with conventional wisdom should be taken as a warning that public reporting of VAP rates may mislead consumers, and other metrics for reporting should take precedence.

Sorry to be Debbie Downer but....

A new study in the American Journal of Epidemiology has found that going to the beach may be more risky than you think. Investigators at UNC-Chapel Hill found that digging in the sand or being buried in the sand was significantly associated with the development of gastroenteritis symptoms in the subsequent two-week period. The risk for illness was overall approximately 20% higher in those with sand exposure, though it varied with the specific beach (at one beach the risk was 90% higher). The study was performed at seven beaches that had sewage treatment plant discharges within seven miles.

Wednesday, July 29, 2009

Scary....

Does the name Betsy McCaughey ring a bell? She's the former Lt. Governor of New York and self-proclaimed expert on healthcare-associated infections, who heads the Committee to Reduce Infection Deaths. Looks like she has a new schtick according to a posting in Andrew Sullivan's blog.

Institute of Medicine to weigh in on PPE for influenza

We’ve blogged extensively about the discordance between CDC and WHO guidance on the use of personal protective equipment (PPE) while caring for H1N1 patients in healthcare settings. You can read our posts on this here, here, here and here.

Looks like IOM is now going to weigh in. You can find their project scope (or “charge”) here, along with links to the committee membership. The project specifies “novel H1N1”, but that seems very silly to me. No robust data exist to suggest that transmission of the novel H1N1 differs in any substantive way from that of seasonal influenza. So any conclusions or recommendations that come from this committee should be applicable to all influenza viruses, not just the “novel H1N1”.

The ad hoc committee has to report its findings to CDC by September 1st. So what do you think the likelihood is that we’ll be using N95s for care of all patients with seasonal influenza, every year?

Don't Get Sick (if you want to stay insured)

Another piece, in Slate, on the odious practice of rescission.

Monday, July 27, 2009

It's not just for chickens, cattle and pigs anymore...

The New York Times today has an article about Chile's salmon production industry, which is the second largest in the world. What does this have to do with infections you might ask? Well, it's about the abuse of antibiotics by the salmon industry, just like that which is occurring in other types of food animal production. And it occurs for the same reason as it does in nonaquatic agribusiness--the animals are kept in extremely crowded conditions, which increases the transmission of infectious diseases, and so antibiotics are added to the food (in this case poured directly into the water in which the fish swim) in an attempt to keep them healthy. In this way, antibiotics enter the human food supply and eventually lead to antibiotic-resistant infections in humans. For example, in Europe vancomycin-resistant enterococci (VRE) in humans can be traced to the use of the antibiotic avoparcin in animal feed. Avoparcin is a glycopeptide antibiotic, the same family of antibiotics to which vancomycin belongs. So when the bacteria colonizing the animals who ate the antibiotic-treated food became avoparcin-resistant they were likewise vancomycin-resistant. Back to the salmon--Chile dumped 718,000 pounds of antibiotics in the salmon's water last year. To put that into perspective, by my calculations, that's equivalent to the amount of antibiotics that could treat 23 million adults each for 10 days.

Restrictions May Apply

I enjoy This American Life, and have been listening to each weekly podcast while I walk to work. This week’s show was entitled “Fine Print”, and covered several unrelated topics wherein reading the fine print turned out to be crucial.

One segment of the show hits pretty hard, and is directly relevant to health care reform—it covers, in a very moving way, the health insurance industry practice of “rescission”. For those of you who live in a developed nation with a sane health care system, “rescission” is a practice whereby an insurer can revoke your health care insurance policy after you become ill, based upon a careful review of your application for any evidence (even minor, technical evidence) that you incorrectly or inaccurately completed your application.

A must-listen for any of you who think our health care system isn’t in desperate need of reform. Click on this link, then “full episode”, and go to 35:22 in the broadcast to listen.

Hospital quality indicators

A group of Australian researchers have published an inventory of hospital care quality indicators that are reported to external agencies, including those related to healthcare associated infections. They have cataloged and classified nearly 400 different metrics. Click here for a spreadsheet of their work.

Religion vs. infection control: issue #4

We have previously blogged about Muslim women who refuse to follow "bare below the elbows" due to the prohibition of having their arms uncovered, the Catholic phlebotomist in England who was sanctioned for wearing a crucifix under her clothing, and the concern in the Church of England regarding transmission of influenza via the communion chalice. Now another issue has arisen. Some Muslim healthcare workers in the UK are refusing to use alcohol-based hand hygiene products when caring for patients with H1N1 influenza on the basis of the Koran forbidding Muslims to come into contact with alcohol. Others are claiming the Koran allows the use of alcohol for medicinal purposes. It seems to me that this issue could be quickly resolved by allowing healthcare workers to wash their hands with another product that does not contain alcohol. CDC currently recommends the use of either an alcohol-based product or soap and water for hand hygiene when caring for patients infected with H1N1 influenza.

Sunday, July 26, 2009

It's time to hang up the white coat

This morning’s New York Times Week in Review section has an article on the white coat and the concerns about contamination by microbes. In a previous posting, I discussed the infection control aspect of the problem with white coats, and the magical thinking held by most physicians that somehow the coat has received a dispensation from the germ theory. Perhaps as interesting as the infection control angle is the issue of the coat’s symbolism and its link to professionalism. There are several papers in the medical literature that discuss the coat’s symbolism. The positive symbolic aspects include candor, integrity, and goodness. Also, it is viewed as a symbol of purity and cleanliness, which is ironic given that two-thirds of doctors wash their coats no more frequently than every two weeks. Negative symbolism has also been described. Some view the coat as a symbol of hierarchy and authority, a marker of social and economic privilege, and a way to denote that the physician is part of an elite community somehow separated from the rest of society.

Dr. Judah Goldberg, an emergency medicine physician and ethicist, wrote a compelling paper in Academic Medicine last year, in which he compares and contrasts professionalism and humanism, and how the white coat fits into these constructs. It's a must-read for those interested in the white coat debate. He writes that one comes to understand humanism simply through the experience of life, whereas, professionalism is acquired through the socialization process of entering a profession. Humanism’s motivation is to serve the welfare of humankind. On the other hand, professionalism’s primary motive is to strengthen professional identity. Most importantly, Dr. Goldberg points out that the outcome of humanism in medicine is to link the physician to the patient. The outcome of professionalism is to separate the doctor from the patient. Thus, once the differences between humanism and professionalism are delineated, it becomes apparent that the white coat serves the latter.

Another physician, Dr. Matt Bianchi, in a paper in the Journal of General Internal Medicine, is able to distill the entire issue into a few sentences as he writes about his own experience:
“I have had the good fortune to encounter a wide and rich spectrum of opinions from patients, friends, and colleagues on the matter of proper physician attire, perhaps encouraged by my absent white coat, absent necktie, shaved head, bilateral black hoop earrings, and tattoos covering approximately 17% of my skin (according to the Lund-Browder burn chart). With only one exception (a mildly demented man in heart failure), every one of the uncommon suggestions to upgrade my appearance for the sake of patient care has come from a physician colleague. In contrast, there have been countless moments of connection with patients who confided that some aspect of my appearance made them feel more comfortable… One can only hope that each doctor-patient interaction affords the participants the chance to transcend the cursory impressions of attire and engage in the “real” work of medicine, the alleviation of suffering and the healing potential of a positive, productive relationship.”

In the end, the white coat is all about the doctor, not the patient. The New York Times article quotes a physician who says, “The coat is part of what defines me, and I couldn’t function without it.” Now that’s magical thinking at it's finest!

Saturday, July 25, 2009

Public health vs. clinical medicine

It’s a typical mid-summer day in Richmond—really hot and very humid. It’s my favorite time of the year (I must have been a plant in a previous life!). So I went to soak up the weather by washing my car. This is a mindless activity that I enjoy because it gives me time to think. I began to think some more about the issue of giving camp kids Tamiflu that I blogged about this morning. It’s a good example of the tension that exists between public health and clinical medicine. As an epidemiologist and a clinician, I can appreciate both arguments. But I have often found myself at odds with public health practitioners over issues like post-exposure prophylaxis. It seems to me that a lot of people in public health have a purist approach and a willingness to play the odds with risk that makes the clinician uncomfortable. Moreover, there’s a detachment that those of us who see patients can’t accept. Don’t get me wrong—I have great admiration for public health practitioners and the important work they do for little money or recognition.

As an example, following a case of meningococcal meningitis, my approach to who should receive postexposure prophylaxis is typically more lenient than my public health colleagues. Given the severity of the disease, the ease of giving a single dose of ciprofloxacin, and the comfort this provides to the contact and family members (a placebo effect of sorts), it doesn’t seem appropriate to me to make a big production of “the rules” about who should receive prophylaxis, especially since the rules are relatively arbitrary anyway. A death from an infectious disease may be viewed as a case by the public health community. To the clinician, it’s a patient—someone’s child, mother, father, brother or sister. A few years ago, I attended a conference about a rabies case given by a public health colleague. It was technically an excellent presentation, but what I remember most was how proud she was about how few doses of rabies prophylaxis were given to contacts of the case. All I could think about was how would she have felt if one of those contacts developed rabies? In the New York Times article from this morning we see the tension between Dr. Marc Siegel (the parent and clinician) and Dr. Anne Schuchat (the public health official), who seems to be applying the rigid rules in a not too empathic way. Maybe public health doctors should spend some time in the clinical setting to be reminded that behind every case of a reportable disease is a real human being and that decisions at the bedside are rarely so black and white.

Hospital infections in the news

Today's news has issues of relevance to hospital infection prevention:

--The University of Wisconsin Hospitals has notified 53 patients that they may have been exposed to Creutzfeldt-Jakob disease after a patient who had undergone surgery at the hospital died of the infection. These patients were operated on with the same instruments used in the CJD patient's operation. Standard sterilization processes may not effectively eliminate the prion responsible for causing CJD.

--A hospital in Utica, New York discloses that 3 patients have acquired Legionnaires Disease, at least 1 nosocomially, over the past few months.

More on Tamiflu at summer camps

This morning's New York Times has an article on the issue of prophylactic Tamiflu at summer camps, which Dan blogged about two weeks ago. CDC says the practice is wrong because it wastes a limited resource and may lead to antiviral resistance. On the other hand, Dr. Marc Siegel, an internist with a child in summer camp disagrees. He argues that his son at camp, with a bunkmate who had influenza, could bring the virus home and infect his brother who has asthma. Given that there appears to be no shortage of Tamiflu at the the present time, I side with Dr. Siegel, and hope that many more kids enjoy a flu-free camp experience.

Friday, July 24, 2009

Mandatory influenza vaccination?

The New York State Hospital Planning and Review Council has passed a regulation that could mandate influenza vaccination of all healthcare workers despite strong opposition from the New York Nurses Association. While I am an avid proponent of influenza vaccination for healthcare workers, believe that hospitals should make every effort to remove barriers to vaccination, and dutifully receive the vaccine every year myself, I remain conflicted about mandating the vaccine. I usually don't have trouble forming an opinion about most aspects of infection prevention and control, but this is one issue that I can't seem to resolve.

Curbing antibiotic resistance

The editorial page of today's New York Times calls on Congress to pass the Preservation of Antibiotics for Medical Treatment Act. The piece notes that 70% of all antimicrobial use in the US is used in animal production, driving our worsening problems with antibiotic resistance. The legislation would place major restrictions on the routine addition of antibiotics to animal feeds.

Thursday, July 23, 2009

Healthcare Reform

Midway through President Obama’s press conference last night, I switched over to ESPN to watch the Red Sox-Rangers game. As I watched the Rangers tie the game in the third inning, it occurred to me that George W. Bush might also be watching the game. After all, he has good healthcare coverage for the rest of his life, thanks to the federal government, and he’s the former owner of the Rangers. So, I pondered, how is it that I am as disinterested in the current healthcare debate as our former president? And why don’t we blog more about this issue?

I can’t speak for Mike, but I haven’t commented upon the current debate for two reasons. First, I don’t find the key elements of healthcare reform all that controversial (and this blog is supposedly about controversies in infection prevention). Among other things, meaningful healthcare reform should provide universal coverage, should reward quality over quantity of healthcare delivery, should pay for preventive care, should prohibit insurers from denying coverage for pre-existing conditions, and should require transparency from hospitals for key infection prevention measures. As a part-time VA doc, I think the federal government can do healthcare, and can do it well. There are certainly controversial elements of the debate, such as how to pay for reform, but those are mostly outside my expertise.

The second reason I’m not blogging about healthcare reform is pure cynicism about our political system. I’m frustrated by the way the media portrays this debate as a political horse race, and with how many politicians use the debate as such. And I’m sad that many, if not most, of the members of Congress are hopelessly conflicted by financial relationships with key interest groups in this debate. Rather than listening primarily to their constituents, who are in constant peril of losing healthcare coverage, being denied care, paying exorbitant rates for inadequate coverage, etc., they keep busy with fundraisers that provide exclusive access to industry lobbyists. Here is a telling section from a recent NPR story on Max Baucus, for example:
"Baucus courts these inside-the-Beltway donors by inviting them to Montana for weekend getaways — skis and snowmobiles in February, fly fishing and golf in June, and coming up on July 31, "Camp Baucus," which is billed as "a trip for the whole family."

Tickets start at $2,500.

So as Baucus and other lawmakers attempt to craft a bill that can smash through a virtual gridlock of interests, the awkward question lingers: To whom are they more attentive — their voting constituencies back home or the dollar constituencies who are at the Capitol every day?"

This explains why I’d rather watch overpaid athletes play baseball. Go Cubs!

H1N1 Miscellany

A detailed article in the NY Times describes what it is like to go to “H1N1 camp” in Maine. My son is just finishing a cross country camp at Colby College in Waterville, Maine, and hasn’t mentioned anything, but we have had some H1N1 at one of our local YMCA camps here in Iowa.

Also of interest, the Church of England realizes it may not be wise to have an entire congregation drink from the same chalice.

Postcard from Latin America #5

Dr. Richard Wenzel writes from Argentina:

Schools are closed, and will be for 4 weeks, and all high risk, young adults (e.g., pregnant women) are not allowed to work. Only young adults screened at hospitals can get oseltamivir. Met with the Minister of Health of Buenos Aires, and he told me yesterday that of 85 deaths in the region - half of the total deaths in Argentina- one fourth were in pregnant women. In Sao Paulo, Sergio Wey told me that there pregnancy was the leading risk factor for severity. In Argentina obesity is a close second risk factor for dying with H1N1. Also in Argentina I was told that diarrhea occurred in 10-20 percent, in the 12 percent range I heard about in Mexico. So far no one has tested stool for virus. I also heard about severe cases in Chile and Argentina in solid organ and bone marrow transplant patients. Not sure how many were nosocomial.

Wednesday, July 22, 2009

Beautiful, soothing……and possibly deadly

Oversight of construction and renovation work is one of my least favorite infection prevention duties. This is especially true when construction plans include beautiful water features. Nothing makes me feel more like a crusty old grouch than having to explain why the perfectly integrated and soothing water feature planned for the oncology unit is actually a fountain of doom.

So I took special note of this report from David Henderson’s group at NIH. This group linked a cluster of nosocomial legionellosis to a decorative hospital water fountain, using pulsed field gel electrophoresis to match isolates from patients with those from the fountain (which was located in the radiation oncology suite). Notably, the fountain was equipped with both a filter and an ozone generator. I heartily agree with the authors that “decorative fountains and water features present unacceptable risk in hospitals serving immunocompromised patients.”

Tuesday, July 21, 2009

Postcard from Latin America #4

Dr. Richard Wenzel writes from Chile:

Made rounds in the adult and peds ICU of one of the university hospitals- hospital clinico UC. They nodded concurrence that about one-third of non-icu admissions have no fever. More interesting they volunteered that half of the outpatients with H1N1 confirmed had no fever. Each had anecdotes that they have screened patients with rhinorrhea only and confirmed H1N1. The point is that the clinical expression of H1N1 is extremely broad. Obviously screening patients with fever will miss many. Lastly, for counting patients, if fever is part of the case definition, the denominator will be greatly underestimated.

The adult in the ICU was an obese 34 year old man whose weight was 150 Kg and BMI was 40. Obesity was recognized informally in Mexico City when I was there earlier. The recent MMWR notes obesity as well. Obviously the question is whether the weight per se is an issue, and maybe these patients have no reserve when they get viral pneumonia. However, I suspect that insulin resistance is a factor: many have underlying hypertension and diabetes (i.e., metabolic syndrome).

Of interest is how H1N1 is managed in Chile vs Brazil. Here clinicians make a clinical diagnosis- confirmation is not essential - and order oseltamivir. The drug is given to patients free of charge.

Sunday, July 19, 2009

Postcard from Latin America #3

Another email from Dr. Wenzel as he travels through Latin America:
Arrived earlier in Chile and will be at the Ministry of Health tomorrow. H1N1 spreading here in their winter but I'll know more tomorrow. Chile prepared well after Mexico. I'll get first hand information in Argentina about their preparations later in the week.

Postcard from Latin America #2

More from Dr. Wenzel as he visits several countries in Latin America:

Had dinner with former fellows- Claudio Pannuti and Sergio Wey- and their colleagues in Brazil. There is an upsurge in influenza thought to correlate with vacationers returning from Argentina and Chile. Pregnancy is the risk factor for severity of illness in cases that they have seen. What is unusual is how the government is managing the outbreak. Ill patients with ILI can be screened in this megacity of approximately 15 million by law only at 7 hospital ERs. The screen is with an immunoblot with a sensitivity of 70 percent. If and only if a patient with a positive screen also has some defined high risk elements will oseltamivir be given. A confirmatory PCR test is then done and sent to a single lab. The results of the PCR are available only after 10 or more days. The important point is that ID specialists cannot write a prescription for oseltamivir or screen for flu; this is controlled by law by the physicians at the 7 EDs.

Sports & staph: A new twist

A soccer player and coach for Australia's Brisbane Lions are both recovering from staph infections following surgery. While MRSA has become a common cause of skin and soft tissue infection in athletes, what is unusual here is that the pathogen infecting these athletes is Staphylococcus caprae, a coagulase-negative staph species that seems to have a predeliction for bones and joints. As the name implies, it's more commonly a pathogen in goats. Interestingly, although both players were operated on at the same hospital, the organism was not thought to be transmitted there, and efforts are underway to decontaminate the team's facilities.

Friday, July 17, 2009

Obesity as a risk factor for severe H1N1?

This MMWR report is worth reading, as a purely descriptive study of 10 patients referred to the University of Michigan with severe H1N1 respiratory disease. Notable findings included the fact that this highly selected population was almost entirely obese (9 of 10) and male (9 of 10). Half of the patients had pulmonary emboli complicating their clinical course, and none had culture evidence of bacterial superinfection as a cause of their severe pulmonary disease. Only 3 of 10 had a recognized risk factor for severe influenza, and the median age was 46. Oseltamivir was administered at high doses (150 mg twice daily) and for prolonged periods of time to all patients, 3 of whom died.

Postcards from Latin America

Our mentor, Dr. Richard Wenzel, is back in Mexico and from there will be heading to Argentina, where an H1N1 outbreak is in full swing and for which a travel alert was just issued. Here is an excerpt from his e-mail yesterday:
Mexico has a new spike of H1N1 cases and the focus is especially high in Chiapas in the south. They have many on respirators with approximately 50 percent mortality - reminiscent of the severe cases in April in Mexico City. Just as in the cases earlier in Mexico City, the Chiapas cases have underlying conditions in only half. Also cases now appearing in Cancun and Merida. Very odd for flu to be here in summer. The big question is how Mexico might distribute the 20 million doses only that they will have by December--to young adults vs high risk young adults vs children who may be efficient transmitters. Even when they target a group, there will be too few doses, and how do you announce the program?
The WHO has quietly announced that it will no longer be tracking H1N1 cases and deaths. The numbers they report have always been grossly inaccurate estimates, given that only a fraction of actual cases are tested. Nations are now asked to report their first few cases only, and to be vigilant for clusters of deaths attributable to H1N1.

I’ve also noticed that, despite all the hullabaloo about the name of this virus when it first swept across the U.S., “swine flu” is now back in vogue. Even the NY Times is back to using “swine flu”.

Wednesday, July 15, 2009

First HHS success story features the Keystone Project

Many of you have probably already seen this—the HHS Secretary, Kathleen Sebelius, is releasing a series of “healthcare success stories” meant to highlight innovative programs or initiatives. These programs are supposed to be models for how a reformed healthcare system would look.

The first success story is from the world of infection prevention, highlighting the Keystone Project. Yes, this is old news to us: any hospital with an infection prevention program should by now have implemented bundled interventions to reduce device associated infections. The challenge going forward will be to sustain reduced infection rates in the face of daunting financial pressures….if hospital layoffs increase, nurse:patient ratios fall, infection preventionist positions remain unfilled, and morale suffers, the team-based prevention approaches that have been so successful may come undone in some hospitals.

More camp closures...

Here is the link to which Kathy refers below, reporting more camp closures, primarily among camps for high-risk youngsters (e.g. those with asthma, muscular dystrophy). Unfortunate for both kids and parents—let’s hope an effective vaccine allows them to enjoy camp next summer….

I’m at my own camp of sorts, on Lake Michigan, so there will be few posts from me this week. Yes, more time away—do I ever work?

Friday, July 10, 2009

Beautiful Camp Inna Fluenza, on Lake Tamiflu

Thanks to Kathy in the comments section for pointing me to this interesting article in Slate, describing an H1N1 outbreak at a Maine summer camp. I understand the desire to hold oseltamivir in reserve for those at highest risk, but I’m still surprised that the Maine Department of Public Health was initially reluctant to use prophylaxis during a clear H1N1 outbreak at a large summer camp. Protecting several hundred youngsters who will soon be boarding buses and planes back to their home communities seems like a smart public health move, regardless of the likelihood that any individual camper will suffer an adverse outcome from H1N1. This issue is picking up speed, with outbreaks at other camps hitting the news as well. I’m also copying, below, a query from a pediatric ID physician in New Jersey, from this morning’s Emerging Infections Network listserve:

"I have received several calls from camp directors or physicians because of influenza in sleepaway summer camps. They are already working in accordance with ACA and state guidelines but as a result, many children are being isolated for 7 days or are being sent home regardless of duration and severity of symptoms without any testing as the current recommendations recommend this regardless of flu test result. In one camp, the sicker children were tested and tested positive for fluA. Now, any child who presents with a single isolated temp above 100 and any other symptom is being removed for 7 days. However, no one is particularly ill and many are well within a day.

For the children who test positive for fluA, the answer is fairly straightforward. However, summer colds and strep do happen at camps and many children may be isolated who either do not need it or who have something else that does not necessitate this (eg, strep after abx). I think it is reasonable for kids with sore throat and fever to be tested for strep--if positive, treat, etc. It may also be reasonable to test those with fever and cough for flu (they are picking it up on their rapid kit with some success)--if positive, follow the guidelines as they currently exist. The quandary is what to do with a child who is negative and is well within two days and whether or not they may return to their bunk and activities.

Obviously the camps will comply with local health authorities. Any other thoughts?"


So what do you think? If you were a summer camp director, or camp nurse, or local public health official, how would you manage H1N1 risk at camp?

Thursday, July 9, 2009

So much H1N1, so little time....

I’m usually pretty good about missing or ignoring important H1N1 developments. The last couple days this has been more difficult:

There is a big H1N1 summit today. This is one valiant attempt to keep us (in the U.S., at least) from becoming complacent about H1N1 during the dog days of summer. The announcement all the media outlets are touting is that our government is going to pump billions into an H1N1 vaccine program slated for October. IF an effective vaccine can be made in large enough quantities by then, state and local public health authorities will need to coordinate a massive campaign—meaning our own hospital seasonal flu campaigns will be occurring in parallel with this H1N1 campaign. We’ll see if hospitals will be distributed enough of this yet-to-be-produced H1N1 vaccine to deliver to our healthcare workers along with the seasonal vaccine.

Oseltamivir (Tamiflu) resistant strains of H1N1 have been isolated on 3 continents—the spread of oseltamivir resistance will further complicate H1N1 treatment and response.

Finally, the new NEJM has several H1N1 related pieces that are worth reading, one about managing uncertainty during the evolving pandemic, one about using commercial airline flight itineraries to predict H1N1 spread (a product of the Bio.Diaspora Project that was begun in response to the SARS experience), and one describing the origin of the H1N1 pandemic strain.

Tuesday, July 7, 2009

Sustaining a gain: difficult in any setting

A new study in the American Journal of Tropical Medicine and Hygiene confirms, yet again, how difficult it is to sustain improvements in hand hygiene performance. The interesting thing about this study is the setting (squatter settlements in Karachi, Pakistan). In 2003, the investigators demonstrated that a hand hygiene intervention (free soap and weekly visits to promote handwashing) successfully reduced rates of childhood diarrhea and pneumonia by over 50% in this population. They returned to the same households in 2005 for a follow up evaluation. Although the intervention homes were more likely to have a designated place for handwashing, there were no longer differences in either soap use or diarrheal disease between the intervention and control households.

Monday, July 6, 2009

If it were only so easy....

The Op-Ed page of today’s New York Times contains a piece by Paul O’Neill, the former CEO of Alcoa, former Secretary of the Treasury and co-founder of the Pittsburgh Regional Health Initiative. He contends that President Obama should propose the audacious goal of asking “medical providers to eliminate all hospital-acquired infections within two years.” It’s another example of the type of argument the mainstream media loves to promote. At its core the premise holds that healthcare providers simply don’t care enough to eliminate infections. And although I would be the first to admit that we still have a ways to go in reducing nosocomial infections, his argument is profoundly flawed in assuming that these infections can be eliminated. I recently gave a talk on healthcare associated infections attended by approximately 75 physicians trained in infectious diseases, most of whom were in practice at prominent academic medical centers. At the outset I asked how many in the audience believed that healthcare associated infections could be eliminated. Not a single person raised their hand. As I have stated in this blog before, I believe the majority of HAIs can be prevented, and progress in reducing infections is evident. But these infections cannot be eliminated and it’s a lie to state otherwise. As I made rounds today, the patients I saw were incredibly ill, many were profoundly immunosuppressed, and invasive therapies were the rule. Moreover, the severity of illness, levels of immunosuppression and use of invasive technologies all continue to increase, making patients ever more susceptible to infections. What we need is less application of naïve logic and more investment in studies to determine the optimal strategies for prevention of infection and how to best implement those strategies in an environment that is increasingly stressed and under resourced.

Back from Ecuador

I had a great trip, and thanks to Mike for blogging solo for the past 2 weeks—I will not be very active this week either, I fear, since I am picking up the ID consultation service today.

Our time in Ecuador was spent almost entirely in the northern and central highlands, and included a lot of high altitude hiking. I’ve attached a couple photos from our travels, one of the Laguna Quilotoa, and the other of the airport fever screening upon our arrival in Quito. “La grippe porcina” was definitely a concern there, and of course is even more of an issue thoughout the southern hemisphere.

Now that it is clear that H1N1 is widespread in many countries of the southern hemisphere, and will likely be circulating here throughout our next influenza season, vaccine questions will become more and more pressing. Will we have an H1N1 vaccine in sufficient quantities for all “at-risk” populations by October? Will one dose or two doses be needed? Will it be incorporated into the seasonal vaccine (no).

If we think it difficult to achieve good healthcare worker influenza vaccine coverage when only one shot is required, imagine a campaign that requires 3 doses! I’m thinking a jab in each arm at first visit, followed by an H1N1 booster a month later….

Friday, July 3, 2009

Possible transmission of hepatitis C from an infected OR technician

The Denver Post is reporting today that nearly 6,000 patients may have been exposed to hepatitis C at two Denver healthcare facilities due to a hepatitis C infected operating room technician swapping her dirty syringes refilled with saline for those filled with fentanyl.

Thursday, July 2, 2009

New York Report on Hospital Acquired Infections

The New York State Department of Health has released its second annual report on hospital acquired infections. The report is nicely done and contains hospital specific data for central line associated bloodstream infections (CLABSIs) as well as selected surgical site infections. Of note, Enterococcus was the leading cause of central line associated bloodstream infections.

Wednesday, July 1, 2009

Top priorities for clinical effectiveness research

The Institute of Medicine has released a list of the top 100 priorities for clinical effectiveness research, which it defines as "the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care." Of the top 100 research priorities, 3 fell into the primary area of infectious diseases, 2 of which directly relate to healthcare epidemiology. Both of these were ranked among the top 25 most important priorities and are:

--To compare the effectiveness of various screening, prophylaxis, and treatment interventions in eradicating methicillin resistant Staphylococcus aureus (MRSA) in communities, institutions, and hospitals.

--To compare the effectiveness of strategies (e.g., bio-patches, reducing central line entry, chlorhexidine for all line entries, antibiotic impregnated catheters, treating all line entries via a sterile field) for reducing health care associated infections (HAI), including catheter-associated bloodstream infection, ventilator associated pneumonia, and surgical site infections, in children and adults.

The purpose of the IOM's project is to identify how to distribute $400 million in federal stimulus funds.