Thursday, December 31, 2009

When flu comes home...

This week's New England Journal of Medicine has a study that looks at transmission of H1N1 flu in the household setting. The investigators studied 216 persons with flu (index cases) and their 600 household contacts over a 7-day follow up period. The attack rate for household contacts developing influenza-like illness (ILI) was 10%. The median age of the secondary cases was 14.5 years (median age of all household contacts was 26). Risk of acquiring ILI was age-dependent (compared to adults aged 18-50 years, children 0-4 years had a 3-fold risk, children 5-18 had a 2-fold risk, while the risk for those over 50 years was one-third that of adults under 50 years). The time from onset of symptoms in the index case to onset of symptoms in a secondary case was a median of 2.6 days.

Tuesday, December 29, 2009

Pomegranates and MRSA

Travelling in Ohio, but had to get in a quick post to suggest what to eat in 2010. Well, not really but perhaps spread on your skin. Researchers in England have found what might be a new class of antibiotic. When mixed with a metal salt, presumably cupric sulfate, and vitamin C, pomegranate rinds have activity against MRSA and other hospital pathogens. You can read the full story in the Guardian here and look at their list of publications here. What I particularly liked is that the story mentioned that there were 20 classes of antibiotics created between 1940 and 1962 but only 3 classes in the 48 years since. I guess if NIH could increase funding for antibiotics beyond the budget dust level, we might have a chance. Hopefully other countries can step in with funding and creative science like this. That is my wish for the new year.

Monday, December 28, 2009

Media and the Public Health Response

Recently, I have become interested in how the media influences the public health response and watched with fascination as the H1N1 saga unfolded. As Mike pointed out earlier, the New York Times has written about the recent transplant-related transmission of Balamuthia mandrillaris and whether this one-off event should change overall transplantation guidelines nationwide. I hope the NY Times' assertion that patients with undiagnosed neurological conditions should be barred from donating organs is analyzed and public health officials don't make a knee-jerk decision based on immediate/transitory media attention or political pressure.

Decisions like these are quite complicated and proper analysis can turn-up unexpected findings. Two years ago, I co-authored an article in the American Journal of Transplantation with Eugene Schweizer and others at the University of Maryland that analyzed what would happen if kidneys were transplanted from donors considered high-risk for HIV or Hepatitis C, yet had tested negative. The current practice is to discard these valuable organs. Our most surprising finding was that the total number of viral infections in recipients was actually LOWER with the policy of transplanting these organs. The reason? It turns out that discarding kidneys from high-risk donors led to more time on hemodialysis which resulted in a higher Hepatitis C incidence in recipients. The transplant policy also resulted in higher quality of life and lower cost of care.

Now, the NY Times article is quite balanced, but this won't necessarily stop public health officials from making decisions before a proper analysis is completed. Let's hope cooler heads prevail before a "national policy on whether to bar people with poorly defined neurological disorders as donors" is decided by officials and not scientists. The one thing that is certain is that there is nothing harder to define than a neurological condition.

More on infections transmitted by donor organs

Over a week ago I noted the two cases of Balamuthia mandrillaris infections transmitted to two organ transplant recipients from a donor in Mississippi. Until today, the media attention had only been local. This morning's New York Times is covering this story and raises the question of whether patients with undiagnosed neurologic conditions, such as the donor in these cases, are acceptable donors or whether they should be excluded from the transplantation process.

Sunday, December 27, 2009

Anthrax in the US

The Associated Press is reporting that a New Hampshire woman is in critical condition due to gastrointestinal anthrax. It is believed that transmission occurred via an African drum. Three other cases of anthrax in the US (2 inhalational, 1 cutaneous) have occurred since 2006 associated with goat hides imported from West Africa for djembe drums. Click here to hear djembe drums.

Saturday, December 26, 2009

Honesty and fairness in public reporting: Some wishes for the New Year

In the latest issue of Critical Care Medicine there is a study that attempts to determine the role of cross-transmission in the development of nosocomial infections. The two-year study was performed in 11 ICUs in 2 large German hospitals. Surveillance for nosocomial infections was performed and all isolates from cultures which yielded 6 indicator organisms (E. faecium, E. faecalis, K. pneumoniae, P. aeruginosa, Acinetobacter, and S. aureus) were archived for genotyping. Also included were MRSA strains obtained from active surveillance. Over the two years, 1,216 nosocomial infections were identified. Molecular typing revealed that there were 462 episodes of cross transmission (i.e., patients shared the same strain).

What are the implications of this study?
(1) 38% of nosocomial infections had an exogenous source (the infection occurred due to an organism transmitted to the patient in the ICU). One could argue that nearly all of these infections could be prevented by better hand hygiene compliance and perhaps to some degree by reduced contamination of healthcare worker clothing (e.g., a bare below the elbow approach to prevent contamination of sleeves) and decontamination of shared patient care equipment.
(2) 62% of infections had an endogenous source (the infection arose from the patient's own microbial flora). Some of these infections could be eliminated with practices such as central line and ventilator bundles, as well as chlorhexidine bathing. However, there will always be infections in this group which are not preventable (e.g., bloodstream infections of enteric origin in the neutropenic patient). Even if 100% of exogenous and 75% of endogenous infections could be eliminated, that would still leave 15% of all nosocomial infections as non-preventable (i.e., the irreducible minimum).

So in an era of heightened transparency and accountability with public reporting of healthcare associated infections, what needs to be done? Here are my wishes for 2010:
(1) CDC needs to improve surveillance definitions to improve specificity. For example, enterococcal bacteremias in the neutropenic patient should be not classified as line associated infections since these are mostly non-preventable infections with endogenous flora.
(2) States with mandatory public reporting of HAIs need to focus on validation of data submitted by hospitals so that consumers can compare apples to apples. In an informal survey of hospital epidemiologists, I recently learned that some hospitals disregard the CDC central line associated bloodstream infection (CLABSI) definition in the case of enterococcal bacteremia in the neutropenic patient, though a strict interpretation of the CDC definition would not allow this. Were we to do this at my hospital, our CLABSI rates in the medical ICU would fall significantly since enterococci are the predominant bloodstream pathogens in that unit.
(3) CDC also needs to allow hospitals to count each central line present in denominator calculations. Currently, one line day per patient can be counted, even though patients may have more than one line present, each of which is a risk factor for infection. This overestimates the CLABSI rates in my medical and surgical ICUs by 20% and punishes hospitals who care for the sickest patients.
(4) CDC and the professional societies need to educate the public with an honest approach to the concept that most, but not all, healthcare associated infections are avoidable. Stop the APIC-driven "targeting zero" doublespeak (zero infections is not attainable but it's an aspirational goal)! It's confusing to patients, punishes the people who are working hard to prevent infections (ICPs, hospital epidemiologists and front-line providers), and undermines the credibility of ICPs in the medical community.

I still believe that public reporting is the right thing to do. But it sure would be helpful to have a level playing field.

Thursday, December 24, 2009

The weekend: It's a good thing!

A new study in BMC Infectious Diseases uses data from eight European countries to model transmission dynamics of an infectious disease spread by close contact in schools. The key finding: the basic reproductive number (the number of secondary cases transmitted by a primary case in a fully susceptible population) falls about 20% on weekends when compared to weekdays.

Wednesday, December 23, 2009

A video worth a thousand words

This week's New England Journal of Medicine has a video using Schlieren optics demonstrating the plume created by a cough with no mask, with a surgical mask and with an N95 mask.The masks redirect the plume upward which may reduce the risk of transmission of respiratory infections.

Schlieren photography allows visualization of transparent material that is not visible to the human eye. The Schlieren photo of a cough shown here (with no mask) is from the New York Times (10/28/08) by Madeleine Robins.

Another H1N1 Vaccine Recall (FluMist)

Maryland-based MedImmune is recalling FluMist doses shipped in October and November after tests showed that it lost strength quickly after shipment. Per the CDC, this is a voluntary and non-safety related recall of 4.7 million doses similar to the one last week by Sanofi Pasteur. I know all indications are that this didn't impact the effectiveness of the vaccine, but I'm sure the anti-vaccine crowd will pounce on this and suggest that the vaccine was rushed and experimental. However, I won't glorify them by linking to them.

The revolving door syndrome

For the second time in a week, I'll refer you to an interesting piece in the blog Effect Measure.

Monday, December 21, 2009

Walter Stamm (1945-2009)

Sad news in the infectious disease world. Dr. Walter Stamm died last week after a long battle with melanoma. His mentorship and science have no doubt touched most who practice ID. He was head of the Division of Allergy and Infectious Disease at the University of Washington from 1994 to 2007. The Seattle Times and New York Times have nice obituaries.

Saturday, December 19, 2009

What is happening to public health departments?

There's an excellent piece in the Effect Measure blog on the shrinking resources in state public health departments. It's sad and scary...

In the news

Just about every day, I take a look at what's appearing in the mainstream media so that readers of this blog can link to the latest, hottest happenings in the world of infectious diseases and infection prevention. Today's foray yielded a treasure trove:
  • First it was Christmas decorations. Then aquariums. Now British hospitals are banning flowers on wards in the name of infection prevention. I suggest they next ban food, water, and air, since none of those are sterile either.
  • Two of four patients who received organs from a patient who died at the University of Mississippi Medical Center last month have been diagnosed with infections due to Balamuthia mandrillaris, a free-living amoeba that can cause encephalitis. Both patients are critically ill. Infections with these organisms are rare, and these are the first to be transmitted via transplanted organs.
  • Dr. Sidney Wolfe, the well known patient advocate at Public Citizen, has added Tamiflu to his list of worst pills. The title of the press release says it all--"Tamiflu? More like Scamiflu."
  • In Scotland, three injection drug users have developed cutaneous anthrax, one of whom has died of the infection.
  • Lastly, if you are planning on having plastic surgery anytime soon in Connecticut, be careful! A plastic surgeon there has been cited because inspectors found mouse poop on her surgical instruments. I didn't make this up, really! See the link here.

Thursday, December 17, 2009

Spiraling empiricism

I did my residency training at the University of Virginia just before ward-based wet labs were eliminated from hospitals....so I fondly (and sometimes, not-so-fondly) recall gathering samples from newly admitted patients and carrying them around the corner to perform a Gram stain, KOH prep, wet prep, or India Ink exam. One patient in particular was very influential in my choosing infectious diseases as a career--a septic patient admitted in the middle of the night to our medical intensive care unit, for whom we made the diagnosis immediately by performing a cerebrospinal fluid Gram stain in a small lab just a few steps away from the unit. Something about the entire experience of caring for that patient, who made a complete recovery, was extremely compelling....but there were a lot of things about my training at Virginia that drew me to infectious diseases. Not least of which the fact that half my medicine ward attendings were ID faculty, beginning with Dr. Ed Hook, who was my first general medicine ward attending.

Anyway, I'm digressing terribly. This post is meant simply to direct you to this piece by Dr. Abraham Verghese, infectious diseases physician and bestselling author. The piece needed no introduction--it's great, just go read it!

Last Minute Gift Suggestions

Who has time to shop these days, with all the CLABSI tracking and public reporting. To satisfy everyone's inner geek, I've compiled a few gift suggestions. (Note: no one affiliated with this blog has any relationship, financial or otherwise, with any of the retailers mentioned or linked)

1) Giant Microbes - Cuddle up with a stuffed E. coli or even an H1N1 virus - perfect for those cold nights.

2) A Staphylococcus aureus bowtie would be nice. Look good and protect your patients. You certainly would be in good standing around here.

3) DNA Mini-Portraits - Swab your cheek, mail it in and get a beautiful picture of your DNA to share with that special significant other. Maybe you could compare a friend's DNA to your locally circulating Acinetobacter strain and marvel at the similarity.

4) Charles Darwin poster - Chicago artist Diana Sudyka has many amazing posters for sale, but none speak to the constant struggle of infection prevention more than the one of young Darwin. If we could just get bacteria to stop believing in evolution our jobs would be so much easier. Come to think of it, we might be out of work all together. Yeah evolution.

5) Finally, from Baltimore - epidemiologist JJ Furuno recently received a frog tank in the mail with everything one needs for a special frog habitat: tank, gravel, rocks, food, bamboo....and two dead frogs. He was pretty sad. We don't recommend shipping living things in the mail, but if you must, wait until summer.

Come to the Decennial!

As I type this, I’m on a conference call to review abstracts for the Fifth Decennial International Conference on Healthcare Associated Infections. Along with a tremendous slate of invited speakers, we have a record number of abstracts, including a lot of very interesting work from around the world. Now is the time to clear your schedule to come to Atlanta in March……if you miss it, you’ll have to wait another ten years!

Also, if you have some interesting, late-breaking research in healthcare epidemiology, the late-breaker abstract deadline is January 29, 2010.

Wednesday, December 16, 2009

Atul Gawande - The Checklist Manifesto

Dan has commented several times on Atul Gawande's New Yorker articles (here and here). As he stated, his writing is highly influential both politically in Washington and in driving patient safety. Those who like his articles and books will be excited to know that he has a new book coming out next week titled "The Checklist Manifesto." You'll be even more excited that you can hear him now on APIC's website and see him July 12th at the New Orleans APIC conference where there will be an "exclusive book signing at the premier conference for infection prevention education." I was going to comment on the fact that SHEA might be considered the premier conference by some, but then I realized SHEA's meeting will be going away in a few years, so it's probably not worth mentioning...

I'm sure we'll write more about his newest book when we've had a chance to read it. In the meantime, I will be sitting next to my fireplace hoping Santa finds it in his heart to place a copy in my stocking.

Tuesday, December 15, 2009

H1N1 Vaccine Recall (Sanofi Pasteur) - Swine Flu Vaccine Recall

Although not a safety-related recall, Sanofi Pasteur has voluntarily recalled approximately 800,000 doses of low-dose, thimerosal-free vaccine in 0.25 mL prefilled syringes used in kids ages 6 months and 3 years according to the CDC. The recall is for reduced potency and impacts the only vaccine type that was thimerosal-free and licensed for children under 2 years old. Kids older than 2 can typically receive the intranasal spray vaccine, which is thimerosal free. I suppose this will create anxiety. However, there is no evidence, after much study, that thimerosal is harmful. The mercury levels are far below those achieved when eating fish. Fortunately, there are declining levels of circulating 2009 H1N1 in the US, so if a child under 2 needs their first or second shot, they can probably wait until new supply arrives.

Monday, December 14, 2009

Why can't we do this in hospitals?

Wouldn't it be interesting if we could get all health care workers to wash their hands when they come to work, before lunch and before they go home? We could at least be sure that they all washed their hands 3x/day! Would it work? Who knows, but a study done in Denmark by Inge Nandrup-Bus did just that in school children ages 5-15 (AJIC December 2009) and reported significant reductions in absenteeism in the intervention school versus the control school during a wintertime 3-month pilot study.

Now, I have some issues with the methods (you can't really randomize only two hospitals, for instance), but all pilot studies can be criticized. At the intervention school all pupils were required to wash their hands when they arrived, before lunch and before they left school for home. All students in the intervention also received 2 lessons in theoretical and practical hand hygiene. Each sink hand a poster above it with proper step-by-step techniques displayed and all students were tracked for 5 types of absenteeism: URI, GI infection, skin infection, other infections and non-infectious reasons.

The multivariate analysis showed that the intervention was associated with fewer absences (0.97 vs. 1.24 periods) and fewer days missed (1.95 vs. 2.65 days). Interestingly this was seen with what can only be described as poor self-reported compliance with 19%, 31% and 9% of students in the intervention school washing their hands every day before school, before lunch and before leaving, respectively. However 52 to 69% did report compliance once in a while (around 50% of the time), so their compliance does stack up well with health care worker compliance rates.

So, should we try this in hospitals? Should we "mandate" and directly observe people coming on/off units? Should we require hand hygiene before entry into the cafeteria or on-site coffee shop?

Saturday, December 12, 2009

Healthcare reform and cost containment

Back in May I flagged an article by Atul Gawande. That piece, which put McAllen, Texas on the map (but not in a good way), illustrated nicely the consequences of the perverse incentives built into the fragmented U.S. healthcare system. The article became required reading in the White House during the debate over healthcare reform.

Dr. Gawande has another article in the New Yorker this week, this one addressing strategies for cost containment. Although failure to more aggressively curb costs has been a common criticism of the current reform bills, Gawande argues that pilot programs such as those included in the bill (including one that would penalize hospitals with high infection rates) are the most promising long-term approach to cost containment and quality improvement.

He uses the history of U.S. agricultural practices as an analogy, arguing for a form of positive deviance writ large--establish small-scale pilots around the country, and expand or replicate those that are successful. The process would be guided by government but not with big comprehensive mandates.

I agree with that general approach to quality improvement and infection prevention, and I think we are already seeing how certain interventions that clearly work (e.g. the central-line associated bloodstream infection prevention bundle) are being more widely adopted. What we desperately need is more funding to quickly study competing approaches and determine what works best.

Thursday, December 10, 2009

Grassroots health care reform

I know this is an infection prevention blog, despite it being only my second day on watch, but I thought I'd wade into the "controversies" end of things. My friend Cary Gross, a physician and researcher from New Haven, helped organize a grass roots event for physicians to support our patients and the Senate healthcare bill. I met with aids for Senators Dodd (CT), Mikulski (MD) and Harkin (IA) and focused on the issues surrounding the comparative-effectiveness research portions of the bill. Specifically, the proposed new non-governmental Institute which could block all funding for 5 years from researchers who attempt to publish findings that the Institute doesn't approve of. I also brought up the lack of funding for antibacterial resistance research- both drug discovery for Gram-negative rods and infection control. I'm not sure how to bring down costs in a post-antibiotic world.

At the end of the day we had a press conference with Senators Reid, Schumer, Murray and Durbin. They were all excited to hear from people that thought they were doing a good job - which they are. Cary and Stan gave fantastic speeches and I thought Stacy's comment about the 'perfect being the enemy of the good' was spot on. It looks like the bill will go to conference and there will be reform! Hopefully before the holidays...and you know, I've had patients with medical charts longer than 2000 pages, so I don't know what the big deal is.

"The Truth about Tamiflu"

A few months ago, Dan and I both blogged (here and here) about an interesting article in The Atlantic that questioned the effectiveness of the influenza vaccine. Now, the same investigative journalists, Shannon Brownlee and Jeanne Lenzer, have a new piece, "The Truth about Tamiflu," in The Atlantic. They examine the controversy about the effectiveness of tamiflu that I blogged about yesterday. Like their previous article, this one is well-written and definitely interesting.

Wednesday, December 9, 2009

Looking for bugs in all the wrong places

A few days ago I blogged about a hospital in England that banned Christmas decorations to reduce the risk of nosocomial infections. Now a hospital in Scotland is removing 11 aquariums for the same reason.

The end of the beginning...

...or the beginning of the end? I want to thank Dan and Mike for inviting me to join the blog. I have always enjoyed reading and occasionally commenting on their posts. This is an exciting time for infection prevention/control. For instance, the new bill (H.R. 3590) currently winding its way through the Senate contains specific language concerning AHRQ's Center for Quality Improvement and Patient Safety that requires research around practical methods to control HAIs including MRSA, VRE and other emerging infections and building capacity for patient safety research. It even authorizes appropriation of $20 million for FY 2010-2014. Given that MRSA alone is associated with 18,000 deaths/year in the US, while antibacterial resistance gets only a small proportion of the $200 million devoted to antimicrobial resistance (antiviral, anti-malarial, anti-TB and antibacterial) by NIH , more funding is desperately needed. So, as awareness and research funding increase we will have more to write about and can finally move forward from what I call the "absence of evidenced based medicine."

In the end, I hope I'm up to the task and high standards Mike and Dan have set and this is the end of the beginning. Perhaps someday we will be able to steal a phrase from Jay-Z and can say "99 problems but MRSA ain't one"

Tami-fly-by-night?

This week's BMJ contains an updated Cochrane Review on neuraminidase inhibitors for treating and preventing influenza. The journal issue also contains several other related articles, primarily focusing on the controversial aspects behind the review. The previous Cochrane Review used a meta-analysis that relied heavily on unpublished data. For the update, the Cochrane reviewers tried to obtain the primary data from Roche, but were unable to do so, and the study in question was eliminated from the new review. The review concludes that the drugs are modestly effective in the treatment of influenza and not effective at preventing influenza-like illness since only a small fraction of ILI cases are caused by influenza. In a separate publication in the same issue, Peter Doshi, one of the authors of the Cochrane review, states: "We are no longer sure that oseltamivir offers a therapeutic and public health policy advantage over cheap, over the counter drugs such as aspirin."  


So, how much money has been spent on a drug of questionable effectiveness?

Welcome, Eli!

Mike and I started this blog almost ten months ago, posting observations about infection prevention issues that we might previously have just e-mailed to each other. It has been a lot of fun so far, and for me it has been a very useful way to focus my thoughts about events and issues as they develop. We’re also happy to have gathered a small but loyal readership.

We are now very pleased that Dr. Eli Perencevich—infectious diseases physician and healthcare epidemiologist extraordinaire—will be joining us! Eli is a talented and accomplished hospital epidemiologist and investigator, and we are excited to add his fresh perspective to our humble blog!

Tuesday, December 8, 2009

Water

After Mike's recent posts on food safety, he asked, "What's next?" As if on cue, the NY Times has a scary front pager on the safety of our water supply. About 20% of U.S. water treatment systems have violated the Safe Drinking Water Act in the last 5 years, but only a fraction were ever fined or punished. One of the more common violations? Elevated bacterial levels.

It's worrying that one of the more developed nations in the world is having trouble supplying safe water to its citizens. The availability of safe potable water is already a global crisis that will only grow more urgent with time.

On a lighter note, learn more about the importance of safe drinking water from General Ripper.

So how bad was the H1N1 pandemic?

According to a new paper in PLoS Medicine, Marc Lipsitch's modelling estimates that among persons with symptomatic H1N1:
  • 1 in 70 required hospital admission
  • 1 in 400 required ICU care
  • 1 in 2,000 died
With data in hand, he argues in an NPR piece that this is a very mild pandemic. Not so, says Dr. Tom Frieden, Director of the CDC. An expert in risk communication speculates that CDC is avoiding describing the pandemic as mild out of fears that vaccine uptake will fall.

Monday, December 7, 2009

Slimmer faster

As if yesterday's posting on contaminated chickens wasn't bad enough, today the Wall Street Journal reports that Unilever is recalling 10 million cans of Slim-Fast due to potential contamination with Bacillus cereus. What's next?

Sunday, December 6, 2009

Carnivores beware!

Consumer Reports has released a study evaluating contamination of store-bought chickens. They tested 382 chickens from 100 grocery stores in 22 states. The results were appalling--62% of the chickens were contaminated with Campylobacter, 14% were contaminated with Salmonella, and 9% were contaminated with both organisms. So if you're gonna eat it, you better cook it well!

Saturday, December 5, 2009

Influenza miscellany

Today's LA Times has an article on the effect that H1N1 influenza has had on the pork industry even though pigs haven't been part of the pandemic. On the other hand, here in Virginia, a flock of turkeys has been found to be infected with H1N1. Also in Virginia, 2 patients have been diagnosed with tamiflu-resistant H1N1, as have 2 patients at Johns Hopkins Hospital. And lastly, H1N1 has been diagnosed in a cheetah in a California zoo.

Scrooge!

A newspaper in the UK reports today that a hospital there has banned the display of Christmas decorations because they are an infection control hazard. What in the world is going on there with regard to their approach to infection control? Recall that some months ago I blogged about a phlebotomist who was fired because of a small piece of jewelry worn on a chain under her shirt on the grounds that this was an infection control risk, and earlier this week I blogged about a piece in their leading infection control publication. As I look at the news items in the mainstream media regarding infection control on a daily basis, I am struck by the fact that the vast majority are in UK publications. Clearly, the public in the UK is very interested in the topic. But you have to wonder whether some of the actions taken in British hospitals are designed more to make headlines rather than a true attempt to reduce infections.

Friday, December 4, 2009

Quieting down on the H1N1 front

Iowa has now officially moved from “widespread” to “regional” to “local” activity. As the graphs below demonstrate, H1N1 has left our state for the time being. We haven’t had a positive influenza A in our hospital lab for over 2 weeks, the percent of visits due to ILI at Iowa ILINet sites is back to near baseline, and the number of patients hospitalized for influenza has plummeted.

Ironically, it is just this week that we got our first really big shipment of H1N1 vaccine (before, it was trickling in a few hundred doses at a time). So we’ll be doing most of the vaccinating after the virus has left town…yes, a “wave number next” could come along, but I doubt we’ll see another big bump in H1N1 cases in our state during the 09-10 season.

Decisions now begin to revolve around “walking back” the H1N1 response….when to lift visitor restrictions, how to approach vaccination going forward, and when we can begin treating H1N1 like……an influenza virus.

Wednesday, December 2, 2009

Azoles on the farm

There’s another agricultural antimicrobial controversy brewing. This time it isn’t antibacterial use in animals, but rather the widespread use of azole antifungal agents to protect crops from fungal disease. The Science summary, here, is good, so read it for yourself (subscription required for access to full text). The bottom line: Paul Verweij's group in the Netherlands is building a strong circumstantial case that agricultural azole use is contributing to the emergence of azole-resistant A. fumigatus infections in humans.

Since I have a particular interest in antifungal resistance, I have long been following the reports from the Netherlands of azole resistant Aspergillus fumigatus infections. Our group has been doing global surveillance for azole resistance among Aspergillus for years, and it has remained very uncommon, although last year we found an apparent cluster of azole-resistant A. fumigatus (we’ll publish the details sometime soon, in collaboration with CDC investigators).

Despite my interest in antifungal resistance, I had no idea until recently that there were so many different azoles being used on crops (at least 30 are marketed for agricultural use!). Interestingly, there is little agricultural azole use in the U.S., far more in Europe and elsewhere. As most of you know, invasive aspergillosis is a devastating infection with a very high mortality rate, and the newer azoles are the drugs of choice for both treatment and prevention in high risk patients. Widespread emergence of azole-resistance among Aspergillus would be a very bad thing, indeed.

Infection control across the pond

An upcoming issue of the Journal of Hospital Infection has a perspective written by Dr. Stephanie Dancer, the journal's editor. Entitled "Pants, policies, and paranoia...," her piece examines the push in the UK to reduce infections by focusing on the role of clothing and poor hand hygiene compliance in infection transmission. Her primary argument is that these issues are distractors from the real problems that are not being addressed by the National Health Service, namely suboptimal facilities that are suboptimally cleaned and understaffed.

She, like many others, argues that no studies have demonstrated that clothing transmits infections. You can read my counterargument here, but I'll simply state that no study has demonstrated that you need a parachute when you jump out of a plane either. Absence of evidence is not necessarily evidence of absence. But most disappointing is her fatalistic approach to hand hygiene: we can't improve it, so why bother? The reality is that with a lot of work, hand hygiene can be improved (see here and here), and I think this can have a major impact on the incidence of infections in hospitals.

I don't have any first hand knowledge about the state of hospitals in the UK, but I can tell you there are many beautiful, spacious, visibily clean hospitals in the US with terrible infection control problems. While it may be true that the NHS is using hand hygiene and bare below the elbows to divert the public's attention from infrastructure problems, I still think infection control is mostly about what happens at the bedside and how well healthcare workers observe good practices.

Tuesday, December 1, 2009

Infections in the ICU: New data, new insights

This week's JAMA contains an important paper and editorial for all of us in infectious diseases and hospital epidemiology. The EPIC II study was a one-day point prevalence study of infections in 1,265 ICUs in 75 countries involving 13,796 adult patients.

Key findings include:
  • 51% of the patients had infections (this includes both community-acquired and hospital-acquired)
  • 71% of the patients were receiving antibiotics
  • Gram-negative organisms accounted for 61% of the infections (up from 39% in the EPIC-I study done 15 years ago)
  • MRSA accounted for 10% of infections
In my medical school psychiatry course, I learned that a delusion is a fixed false belief. And it's a delusion to continue to think that hospitals should fixate on MRSA and continue with a search and destroy strategy. The gram-negatives are a major threat not only because they are increasing in incidence but also because the therapeutic options are quite limited.