Sunday, February 28, 2010

Secondhand woes

The Baltimore Sun had an article this week on reprocessing of single-use devices. This was quite a controversial topic for hospital epidemiologists about 10 years ago, but I hadn't heard much about it recently. Now there's a new argument for it--it's good for the environment. I also think the green argument could be used to encourage alternatives to contact precautions giving the vast amount of consumables it requires. Anyway, in 2001, I wrote a piece about reprocessing of single-used devices that has survived multiple hard-drive to hard-drive transfers but I never did anything with it. So I dug it out and pasted it below.

Secondhand Woes
Healthcare is not the profitable venture it once was and hospitals in the United States have fallen on hard times. In an attempt to stay afloat, hospitals have looked long and hard at ways to reduce cost. To that end, healthcare consulting firms have advised hospitals on numerous ways to cut corners, going so far as to recommend that bed linens not be changed on a daily basis.
One area of cost savings that hospitals have found quite tempting to explore is the re-use of medical devices that are labeled by the manufacturer for single use only. Obviously manufacturers of medical devices have an incentive to label products as single use so that more devices will need to be purchased. However, some devices should be used one time only based on the type of materials used in manufacturing or by a design so intricate that cleaning of the device is not feasible. Nonetheless, many single-use devices can be appropriately sterilized without damaging the integrity of the product, and reused without difficulty. Consider the case of the $600 catheters that are used by cardiologists to test the heart for abnormal rhythms. These catheters are typically inserted into a major blood vessel and threaded into the heart. Many hospitals have found that the reuse of these catheters after sterilization can result in significant cost savings. This is only one example of the hundreds of products labeled as “single use” that can be reused after appropriate reprocessing.
In response to the increasing frequency with which single-use devices are being reused in hospitals, the FDA has issued guidelines to standardize the cleaning and sterilization process so that the reused devices are safe for patients. This will heighten the accountability of hospitals and businesses that provide reprocessing services.
As a physician trained in infectious diseases, microbiology and public health, I must admit that I am bothered more by the ethical issues surrounding reuse of devices labeled as single use only, than I am about the potential for the transmission of infectious diseases via these devices.
Clearly, there does exist a small risk of transmission of infectious diseases via reused devices. However, it seems likely that this risk is no higher than for the thousands of devices designed for reuse, and which are, in fact, routinely reused after sterilization. Most surgical instruments, for example, are reused on a daily basis in hospitals without any problem. Of course, any process that involves humans is inherently prone to error and therefore entails some risk.
The ethical questions surrounding reuse of single use devices are, I believe, more challenging. First, do patients have the right to know if their procedure will involve the reuse of a product designed and labeled for single use? If they have this right, do they have the right to request that a new device be used for their procedure? And what do we do when patients refuse to accept a used device?
The ethical quagmires don’t end there. Much of the cost savings that can be generated by reusing devices occurs by charging all patients the cost of a new device, even though some patients will not get a new device. How many of us would be willing to pay the factory sticker price for a used automobile? Moreover, how incensed would we be if we paid the sticker price for a car we thought was new, but was not? We have laws that prevent this type of fraudulent activity.
Lastly, which patients will receive the new devices and which ones will get the reused? Could it be that indigent patients will end up with the hand-me-downs, while insurance-card-carrying patients will get the shiny, new ones?
The ethical questions are really not that difficult to resolve. First, hospitals should inform patients on admission about their policy for reuse of single-use devices and supplement this with a brochure that gives patients who want more detail the information they need. Physicians performing procedures involving these devices should ensure that patients understand the issues. Secondly, it is imperative that hospitals that decide to reuse devices develop a system that insures that the selection of a device for a patient is done in a completely random manner. In this way, the corporate executive stands the same chance of receiving the used device as does the man who lives under the bridge. Lastly, the charges for devices must be adjusted to reflect the number of times a product can be used. If a product can be reused five times, then the charge for the product should be the new charge divided by five, plus the cost of reprocessing. If hospitals prorate the charges, the financial impetus to reuse devices may melt away.
The patient must come first. And putting patients first requires honest dialogue. Healthcare administrators must not allow the bottom line and deceptive practices to be guideposts for the way that we provide care because the doctor-patient relationship is too precious to be subjected to harm by dishonesty. What’s best for the patient is, in the end, what’s best for all of us.

Saturday, February 27, 2010

Move over, MRSA!

This morning's New York Times has a piece by Andrew Pollack on healthcare associated infections. That in itself is not a surprise anymore since the general public is quite interested in the topic. What is surprising is that the article isn't about MRSA--it's about Acinetobacter and the lack of effective drugs to treat multidrug resistant gram-negative organisms. Could this be a harbinger that the fixation on MRSA is starting to wane? Pollack remains, to my knowledge, the only journalist that has linked the frenzy to culture inpatients for MRSA with big profits by the companies who manufacture the MRSA testing kits.

Friday, February 26, 2010

Preventing nosocomial bloodstream infections in children

As is the case in many areas of health care, there is less published literature on nosocomial infection prevention in children than in adults. So it is nice to see some multicenter data on central-line associated bloodstream infection (CLABSI) prevention in kids. The bottom line: in 29 pediatric intensive care units (PICUs) across the U.S., implementation of bundles for line insertion and maintenance resulted in a 43% reduction in CLABSI rate (from 5.4 to 3.1 infections per 1000 central line days). One of the interesting findings from this study was that adherence to the “maintenance bundle” seemed to be more important for CLABSI prevention than did adherence to the “insertion bundle”. See here for what each bundle included.

Wednesday, February 24, 2010

Designing out the bugs, take 2

Mike posted last week on a UK design competition for products that might improve infection control in hospitals. Now there is a newly designed keyboard that can be easily cleaned with a disinfecting wipe because it's totally flat. There's a trackpad on the keyboard, thus removing another source of contamination - the mouse. The cleankeys keyboard can be purchased here. The cheapest version sells for $400. Hopefully with scale, the price will come down.

Importance of Family

This isn't a typical post. I'm not linking to any new research findings. Rather, I wanted to refer you to a story I just read on Paul Levy's blog about a friend of his who just died from synovial sarcoma. The story is really the remarks the deceased's daughter gave at his memorial service. She describes how she and her dad worked together to fight his disease; she would read the literature and sift through the statistics and give her dad just the information he needed to keep fighting. I found it particularly moving.

There may be some lessons in there about how families can prevent their loved-ones from developing an HAI. Perhaps we need to figure out ways to engage family members to be constantly vigilant of hand hygiene and glove compliance, for instance. The literature seems to suggest that a continuous Hawthorne effect is the most effective way to improve compliance with hand hygiene. If we can empower daughters and sons and mothers and fathers, like this daughter was empowered, it could make a big difference.

Tuesday, February 23, 2010

Compliance with contact precautions: Not so much

Elaine Larson's group has a new study in the American Journal of Infection Control that examines compliance with contact precautions at 3 hospitals in New York City. She found that 15% of patients who had indications for contact precautions were actually not isolated. For patients who were isolated, hand hygiene by healthcare workers on room entry was very low at 22% and on room exit at 59%. Compliance with gowns was 71% and with gloves 72%.

With the compliance levels demonstrated here it seems unlikely that these hospitals could be successfully preventing infections. I am increasingly convinced that effective infection prevention hinges on high levels of compliance with very basic practices. It's not rocket science.

HAIs: An even bigger problem than we thought?

Our fellow blogger, Eli, has co-authored an interesting study in this month’s Archives of Internal Medicine. Using a national administrative database that contains 69 million hospital discharges, the investigators examined the attributable outcomes associated with two hospital-acquired infections—sepsis and pneumonia. The outcomes were stratified as to whether they occurred in association with a surgical procedure or not. When sepsis occurred post-operatively, it added on average 11 days to the hospital stay and $33,000 to the cost of care, and carried a nearly 20% attributable mortality. Post-operative pneumonia on average added 14 days to the stay and $46,000 to the cost of care, and had an attributable mortality of 11%. For cases not associated with surgical procedures, when adjusted for the preinfection length of stay, sepsis on average added 2 days to length of stay at an additional cost of $6,000, and was associated with an attributable mortality of 16%. Hospital acquired pneumonia in nonsurgical patients added 4 days to length of stay on average, added $11,000 to the cost of care, and had an attributable mortality of 10%. Extrapolating to the US population, the investigators estimated that these two conditions account for over 2 million hospital days, $8 billion in costs, and 48,000 deaths.

Diving into the murky sea of administrative data is a perilous business, but the authors of this paper took great pains to use diagnoses for which validation has been shown to be high level and were careful in their methods to minimize bias and confounding (the methods section of the paper is about twice as long as the results). The incidence of each of these complications is about 1% or less, which makes it difficult for the average clinician to assess impact in their patients. Importantly, what this study does not tell us is the fraction of these cases that are preventable. However, even if only a quarter are preventable, this paper tells us that healthcare associated infections are a big, big problem, and those of us who work in infection prevention have a very long journey ahead. 

Lastly, this study should remind us that our targets should be infections not organisms. This problem is too big to tackle one organism at a time. To the patient with life-threatening sepsis, it matters little whether the cause is MRSA, MSSA, or a multidrug-resistant gram negative rod. Multipotent interventions driven to high levels of compliance will be necessary to ultimately bring these infections to the irreducible minimum.

Saturday, February 20, 2010

Designing out the bugs

This month's Metropolis magazine, a publication that focuses on architecture and design, has a treat for hospital epidemiologists--the results of a design competition in the UK for hospital products that improve infection control. The title of the competition was "Design Bugs Out." The magazine's website has a photo gallery of the newly designed products. Check out the wheelchair that doubles as a beside commode--always good to think about multitasking! I also like the IV tubing that tells you when it needs to be changed.

Photo:  The Design Council

Treatment of latent tuberculosis: efficacy vs effectiveness

I've blogged before about the poor options we have for treating latent tuberculosis. The standard regimen, 9 months of isoniazid (INH), is too long and too toxic for the treatment of tuberculosis that is not active. For patients that aren't immunosuppressed and not recent skin test converters, the risk for developing active tuberculosis is only about 5%. Though the data for efficacy are not as robust, the 4-month daily rifampin regimen is much easier and better tolerated, and I have become more comfortable with this regimen. Because of the referral nature of my practice, the patients referred to me for evaluation of latent tuberculosis often have elevated liver enzymes at the outset or may not want to wait 9 months to complete the standard regimen before starting a therapy they feel is important (e.g., TNF-alpha inhibitors or other immunosuppressants).

A new study reported in this month's Chest examines completion rates of latent TB treatment courses. The investigators found that less than half of persons started on a treatment course actually finish it. About 45% complete a 9-month course of INH, 55% complete a 6-month course of INH, and nearly 65% complete the 4-month rifampin regimen. This leads me to wonder: even if 9 months of INH were ultimately proven to be more efficacious, perhaps 4-months of rifampin is more effective. Efficacy refers to how well a therapy works under ideal conditions (i.e., you take all the doses as prescribed), whereas effectiveness refers to how well a therapy works under real-world conditions (i.e., how well does the drug work when compliance is factored in). Given the toxicities of INH and the longer duration of treatment, coupled with the results of this survey, it's not far-fetched to conclude that what is considered our most efficacious regimen for latent tuberculosis may be our least effective.

Friday, February 19, 2010

cfr-mediated, linezolid-resistant MRSA outbreak

Investigators from Madrid report in CID a 15-patient outbreak during April to June 2008 caused by linezolid-resistant MRSA. As if the outbreak wasn't scary enough, they report that it's mediated through a new mechanism, the cfr gene. Since linezolid is a synthetic antibiotic with no analog in nature, linezolid resistance was thought to be rare and only result when a point mutation occurred at the drug target site. These investigators report that all strains in this outbreak lacked the point mutation but rather each had the cfr gene.

The cfr gene is naturally occurring in bovine staphylococci and mediates resistance to chloramphenicol, florfenicol and clindamycin. It has also been found in porcine isolates. In animals the gene is found on plasmids and is thought to be transferable between staphylococci; there is a suggestion that in human strains, while it is chromosomal it is likely on an integrated plasmid capable of excision/mobilization/transmission to other pathogens and could spread quickly.

It's possible that this type of resistance will be more difficult to control since the gene can hop aboard non-pathogenic species that we don't screen for, like coagulase-negative Staph, evade our detection and spread resistance to otherwise linezolid-sensitive strains, be they MSSA or MRSA. In addition, this type of transmission, of genes not bacteria, may be the Achilles' heal for antimicrobial use in livestock. If you are going to argue that pig strains are different from human strains as a reason to allow antimicrobials in animals, this argument doesn't seem to hold water if it's the genes that spread and lead to resistance. I take that back. It may not be an Achilles heal but rather a Trojan Horse.

Tuesday, February 16, 2010

Polar Bear Poo (and you)

Whenever you hear a hospital epi person complaining about collecting peri-rectal swabs for research or clinical purposes, you could remind them of this study (or here for another summary). Researchers from Norway wanted to determine if resistance genes were naturally occurring or if they were products of the exposure to "the selective pressure of pharmaceutically produced antibiotics." They were specifically interested in β-lactam antibiotics and the β-lactamases produced by blaTEM genes.

They couldn't just go swab pigs since they are exposed either directly or indirectly to antibiotics through close contact with humans. Thus, they wanted to find an animal without close contact with humans and they couldn't just pick up feces since they could have been contaminated on the ground. So, they grabbed their tranquilizer guns, hopped into their helicopters and found 10 polar bears, 5 in 2004 and 5 in 2006, to shoot. (I wonder if they could see Russian from their copters?) They then got the 10 rectal samples directly from the bears after each signed their HIPAA and consent forms.

When they tested the isolates for blaTEM by PCR, only 4 of 144 isolates were positive and all were in E. coli isolates. These levels were far below what has been detected in other wild or domestic animals and certainly in humans. Perhaps this is good news, since it suggests that removing unnecessary antibiotic exposures in humans and animals may lead to lower density of resistance genes and less resistance.

Sunday, February 14, 2010

New frontiers in hand hygiene

Of late I have been attending on the infectious diseases consult service, which accounts both for my infrequent posts and for the dry skin on my hands. Whenever I am on service during the winter, the combination of dry, cold air and hundreds of extra hand hygiene opportunities takes a toll on my hands.

So I enjoyed reading this piece about a plasma-based method for skin disinfection that is being developed in several research laboratories. It has been a long time since my college physics course, so I had to go back and review the definition and properties of “plasma” (the ionized gas, not the bodily fluid).

UK anthrax outbreak expands

The anthrax outbreak among IV heroin users in Scotland continues to expand. There have now been 19 cases in Scotland, of whom 9 have died. There have also been two fatal cases outside of Scotland, one in Germany and the other in London. At least 14 of the Scottish cases and the German case have been proven to be caused by the same anthrax strain. Prior to this outbreak the only other reported case of anthrax in an IV drug user occurred in Norway in 2000.

Meanwhile, unrelated to the European outbreak, the woman with gastrointestinal anthrax in New Hampshire, who became infected from a djembe drum, remains hospitalized but continues to improve.

Wednesday, February 10, 2010

Farm to Fork - Antibiotics in animal feed

The use of antibiotics as growth promoters in farm animals has always been a concern of mine. David Smith published this paper in PNAS back in 2002 that suggested antibiotic use in animals helped initiate the appearance of resistant strains early in the epidemic. Catie Couric on today's CBS News highlighted the risks associated with the use of antibiotics as growth promoters and showed how the Danish (and then Europe) were able to ban them which led to far less resistant bacteria in animals and food. She highlighted Tara Smith's and Dan's study published last year that showed high MRSA rates in swine and production workers. I hope she sticks with this like she did the colonoscopy - colon cancer prevention issue, which has been so successful. It was encouraging that Joshua Sharfstein, Deputy Commissioner of the FDA - and until last year Baltimore's Health Commissioner, recognizes this as an important public health problem. Now if he could just come back to Baltimore and help us shovel. (thanks for the tip dad.)

Another worry for the hospital epidemiologist

This morning's New York Times has a long piece on long-term acute care hospitals (LTACHs). The article focuses on quality and safety issues in these facilities, many of which are for-profit. From the epidemiologic standpoint, these hospitals pose special problems since patients are admitted there from many acute care hospitals typically after long stays and are colonized or infected with multi-drug resistant organisms (MDROs). The LTACH patients then may require re-admission to the acute care hospital after colonization or infection with other MDROs. So in essence the LTACH serves as an amplifier for MDROs. There's a nice review on the infection control issues associated with LTACHs by Munoz-Price in an issue of CID from last year.

Tuesday, February 9, 2010

Not to be too Cavalier about this…..

….but I’ve never been very worried about communicable disease outbreaks from drinking water fountains (decorative fountains and Legionella, that’s a different story).

Nonetheless, Cleveland’s professional basketball franchise has removed all water fountains from the Quicken Loans Arena, as part of a new “cleaning and sanitizing” effort. Team spokesman Tad Carper cited the “national health landscape” as the reason…which I think harkens to one of Eli’s interests, the role of the media in generating irrational fear and free-floating anxiety about mega-superbugs (if I'm not mistaken, Eli is also a Cavaliers fan).

Despite their protestations to the contrary, I can’t help but suspect this is a plot to increase bottled water sales.

Monday, February 8, 2010

The Keystone Project: Part 2

By now nearly everyone is aware of the landmark study by Peter Pronovost and his colleagues that demonstrated significant reductions in the rate of catheter-related bloodstream infections (CLABSIs) in 103 Michigan hospitals (the Keystone Project) with the implementation of relatively simple interventions (handwashing, full barrier precautions, skin prep with chlorhexidine, avoidance of the femoral site, and removal of unnecessary catheters). He has just published a follow-up study in BMJ (free access to the paper here) in which 90 of the original 103 ICUs continued in the project and were able to sustain the reduction in CLABSIs.

It seems to me that without question, the checklist which contains the interventions, should be standard practice for all central line insertions. But what interests me is how the quality community and the infection prevention community approach problems differently. I plan to write more about this in a future posting, but will focus on one aspect of those differences here. The quality folks convert problems to projects and bring people together to implement solutions (collaboratives). The Keystone Project is a great example of how successful this can be. But a critical question is what happens when there's no longer a project? It would be interesting to know what happened to CLABSI rates in the hospitals that dropped out of the project. Can CLABSI reductions be sustained without a project to drive practices or could the checklist intervention become standard practice without any further need for a team, meetings, etc. To some degree, it seems that QI has more of a short-term view. As a hospital epidemiologist, I think we sometimes stumble because we want the ultimate, long-term solution and become overwhelmed at how daunting that can be. On the other hand, we're in this for the long haul, so the challenge is ultimately ours to develop sustainable solutions that are at least semi-autonomous. Does it take a village to continually reduce infections or does it take a village to just get it started? Or maybe the key question should be why should it ever take a village to implement safety practices? Could it be that we just can't or won't hold clinicians accountable and continue to defer to their autonomy?

Sunday, February 7, 2010

H1N1 vaccine: they can't give it away

There's been a fair amount of media coverage on the latest Harvard poll on H1N1. I just went through the results of the poll, which can be viewed here, Slightly over 1,400 persons nationally were interviewed, and the poll has a margin of error of +/- 3.2% at a 95% confidence interval. The poll found that only 21% of adults have received the H1N1 vaccine, and of those who did not receive it, 58% cite they are concerned about the safety of the vaccine. Of those with children surveyed, only 36% reported that all of their children had been vaccinated with another 4% reporting that some of their children had been vaccinated. Of those whose children were unvaccinated, 75% cited safety concerns. Lastly, only 48% felt that healthcare workers should be required to receive the vaccine.

Given the amount of money and effort that has gone into this public health endeavor, I would rate the vaccination campaign as a failure. But I don't think that CDC should bear most of the blame for this. Unfortunately, the public couldn't be convinced that this vaccine is safe. Overcoming the constant stream of misinformation wasn't possible, and many people have difficulty sorting out the information that is credible. What I thought was particularly striking is that only half wanted healthcare workers to be required to get the vaccine. Given how tough consumers have become on healthcare workers with regards to transmission of infection in the hospital, I think that's a true measure of how badly this vaccine was viewed.

Unless there is an upsurge of H1N1 cases in the near future, I doubt that vaccine uptake will increase. The cake is baked.

Thursday, February 4, 2010

Thar’s gold in them thar nostrils!

The wisdom of screening anybody with nares for MRSA carriage may still be questioned, but one thing is beyond doubt: there’s a lot of money to be made in the screening biz.

Cepheid, which already has a “sole source” contract with the VA healthcare system, just inked contracts with two more integrated delivery systems to start MRSA surveillance programs. With fourth quarter revenues soaring 30% (to almost 50 million dollars), Cepheid’s CEO declared MRSA to be the “key driver” for their increased sales figures. Some of this money is put to use lobbying for bills that mandate MRSA screening, some helps fund “opinion leaders”, consultants and researchers, and some helps investment portfolios grow.

By contrast, the methods Mike outlined for eradicating MRSA from his ICUs do diddly-squat to stimulate the economy.

Weather or not!

Posts may be a little light these next few days. At least 2/3 of our crack team of bloggers are in for a major snow event. Some models are predicting up to 3 feet of snow with average estimates closer to 2 feet. Notice that weather reporters like to scare us (Paralyzing in italics!!) as much as health reporters. I guess this is the Mega SuperStorm!

Wednesday, February 3, 2010


As if on cue, the media is abuzz with a new dire threat. This time there is a mega superbug called MDR-acinetobacter. The good news is that David Paterson of the University of Queensland, has a new Australian government grant to assist in the development of new antimicrobials. He has received $2 million over 5 years to study this Mega Superbug. That's a new term for me. Perhaps if we have antibiotics to treat the infection they are just superbugs but if there are no effective antibiotics it becomes a mega superbug. I think someone should write a guideline to clarify this - but that would also take a $2 million grant, I suspect. There is a nice picture of David here for those of you, like me, who miss seeing him since he left Pittsburgh. I hope there is funding at NIH that can assist in drug discovery for MDR-Gram negative rods, since we don't have many options currently.

Atul Gawande - Interview

Recently, Atul Gawande sat down with Rahul Parikh, MD in to discuss healthcare reform, checklists and music. It's an interesting discussion on changing the healthcare system and improving quality including the need for better data. The interview occurred before the Massachusetts Senate election, so it seems at times like it was written decades ago when there actually was hope for healthcare reform. Final note: I agree that Radiohead ruled at some point, but as far as ruling the day, perhaps Spoon or Super Furry Animals should have been mentioned. (Thanks John Cole)

Tuesday, February 2, 2010

Media and MRSA

I find it interesting to read media accounts of MRSA infections. I'm not sure if it's denialism of science, trying to stir up ratings or just plain ignorance, but it's surprising the way the media portrays certain types of infections, especially MRSA. Take for example the sad story of singer Etta James and her battle with Alzheimers and now apparently MRSA. CNN said she was "diagnosed with MRSA -- a bacterial infection resistant to many antibiotics." So far, so good. The Guardian says she is "suffering from a blood infection and the MRSA superbug" while the CBC says "She is fighting the superbug known as MRSA — a bacterial infection resistant to many antibiotics." My favorite is the music website that said that she "has contracted the potentially-deadly MRSA virus since first undergoing treatment."

So we have a bacteria, a suberbug and a virus. Which sounds scarier? I would say superbug, then virus then bacteria. In any case, these representations or social representations of MRSA have been used by the media since at least the 1990's to spread fear and assign blame. This topic will become a recurring theme of my posts surrounding a talk I'll give at the 5th Decennial in Atlanta at the end of March.

By the way - how is this information getting out about Ms. James? HIPAA?