Friday, April 30, 2010
So what happened? Only good things. Universal gloving compliance was 78% in phase 2 and was associated with higher hand hygiene compliance on entry (5% higher) and exit (12% higher). It also appears that universal gloving was associated with reduced CLABSI and catheter-UTIs, but with p-values = 0.1 for both outcomes. C. difficile was also lower (2.0/1,000 patient-days down to 1.4/1,000) but this finding was not statistically significant, p=0.53. VAP rates were the same (1.0 vs 1.1/1000 device days) The most important finding, in my opinion, was that HCW were less likely to have MRSA and VRE contaminating their hands during the universal glove phase. Despite what the authors state (Mike don't be mad!), the study was not likely powered sufficiently to find reduced acquisition, given that MRSA acquisition was reduced by 50% with universal glove (2.9/1000 patient-days vs. 1.4/1000 patient days) but this had a p=0.2.
I think overall, that these findings suggest that universal gloving shows promise warranting further study. I wonder if they stopped universal gloving after the study period? If they did, this would make for a very epidemiologically sound quasi-study (roll-in and roll-out) which could be analyzed using more powerful segmented Poisson regression,which can detect a change in slope and intercept associated with starting or stopping the intervention.
The June ICHE just appeared online 5 minutes ago...more exciting evidence for us to review!
Thursday, April 29, 2010
They examined at a 5-year cohort (2002-2006) of all total hip arthroplasties (primary and revision) and looked to see who developed SSI, using CDC definitions. After controlling for age, gender and NNIS index, patients who had a revision total hip arthroplasty had twice the odds of SSI compared to primary surgery (OR=2.2, 95% CI 1.3-3.7). The difference was even more stark when outcomes were restricted to deep or organ space SSI with revisional surgery associated with four times the odds of SSI (OR 3.9, 95% CI, 2-7.9). One note, they didn't appear to control for duration of surgery as a confounder, even though it was associated with both revisions and SSI. I think this is correct. They were not completing a risk-factor study, but were interested in outcomes.
The usual caveats apply to these types of studies including a single center study and a relatively unique single center at that. However, this is an important study and if these findings hold up at other institutions, which they most certainly will, this suggests that the case-mix of revision and primary hip arthroplasty must be taken into account when SSI rates are reported and hospitals compared. Perhaps an easier solution, as the authors suggest, is to treat them as two different animals, if you will, and report them separately. Also, if one wanted to target specific infections or high-risk procedures, these results suggest targeting revision surgeries over primary ones.
Note: Surbhi is joining the group at my old Maryland stomping grounds and I know everyone is excited for her to arrive.
Wednesday, April 28, 2010
I've already stated previously, that I don't know what a metaphor is, so it won't be a surprise to you that I'm not sure if this coat qualifies as a true oxymoron, a physical oxymoron or is just ironic. I do think it sums up my feelings towards infection prevention these days. We are driven by the desire for zero infections, which while good in theory, can have unintended negative consequences. This white coat is a perfect example: Good for education (although I suspect that is debatable) and bad for spreading pathogenic bacteria (MSSA, MRSA, Acinetobacter) from patient to patient.
Anyway, Dan's post below is more interesting, so please move along.
Tuesday, April 27, 2010
There have been several critiques of PowerPoint over the years (one of my favorites, here, is a PPT summary of the Gettysburg Address). But the program remains among the most commonly used tools for disseminating information in health and medicine.
An interesting piece in today's NY Times discusses the military’s increasing use of PowerPoint, and the accompanying backlash. A good summary quote, here:
“[PowerPoint is] dangerous because it can create the illusion of understanding and the illusion of control,” General McMaster said…..“Some problems in the world are not bullet-izable.”
I agree that using PowerPoint can be detrimental when the objective of an interaction is to spur action or implementation….as it tends to convert the audience to passive recipients of neatly packaged information, rather than active participants and problem solvers. For example, if you are presenting plans for bloodstream infection prevention to your ICU staff, one of your slides might contain bullet points recommending “culture change” and “administrative engagement”. What does that mean?
"Senior officers say the program does come in handy when the goal is not imparting information......news media sessions often last 25 minutes, with 5 minutes left at the end for questions from anyone still awake. Those types of PowerPoint presentations, Dr. Hammes said, are known as “hypnotizing chickens.”
Monday, April 26, 2010
To cut to the chase, since this post shouldn't be longer than the original concise communication, there were 30 non-secondary BSIs in the CCMU, 10 were CLRBSI and 20 were CLABSI. Of the 20 CLABSI, 9 (45%) were considered to have central line sources, 9 were considered contaminated blood cultures and 2 were considered transient post-op BSIs. Of the 8 non-secondary BSIs in the SICU, there were no CLRBSI and 5 (63%) were intra-abdominal sources and 1 unknown non central-line source leaving 2 confirmed CLABSI. Thus, of the original 38 IP-reported CLABSIs in the two ICUs, ID physicians confirmed 21, leaving them with an positive predictive value of 55%; close to flipping a coin.
Now, I didn't read the discussion section of the paper (who has the time!), however, since they only looked at IP determined CLABSIs they can't report sensitivity or specificity; in fact they didn't calculate the PPV, I did that. Given that so many CLABSIs appeared to be contaminated blood cultures, efforts could now be directed to preventing those, but the clinical benefit to the patient would likely be small apart from a few avoiding unnecessary antibiotic exposure. Efforts spent limiting those non-BSI CLABSIs, I suspect will be undertaken since we all have to get to zero. It's just sad that those efforts won't help our patients.
Friday, April 23, 2010
Another shortcoming--what to do about adverse events and nosocomial infections? Shouldn’t a patient also receive goods or services if he or she is harmed during the delivery of health care? I can see it now…returning home after a hospital stay complicated by a nosocomial infection, you discover that the hospital has sent someone over to paint your house…
Wednesday, April 21, 2010
Interestingly the also found significantly greater vent-free days, ICU-free days, successful weaning and ICU discharges in the early tracheotomy group. There was even a trend towards higher survival in the early vs late group, HR=0.80, 95% CI 0.56-1.15. The authors and editorial do a nice job of pointing out that 31% or early and 43% of the late group didn't even receive a tracheotomy due to impending extubation or death. The editorial even makes the point that selecting an early tracheotomy is really a strategy of more trachs. The study did not assess patient comfort, which may be associated with early tracheotomy.
What is always troubling to me is that scientists, editorialists, journals and clinicians are stuck in this p-value trap. Here we have a study, a very good randomized trial, which shows likely clinically significant reductions in VAP and potentially lower mortality, but since the study was underpowered we are forced to say "no difference." I wonder if you calculated how many patients are intubated each year in the US (or Italy) and reduced VAP rates by 33%, how many VAPs would be prevented and how many deaths would be prevented? I know this study should be repeated, but will it? You have a negative JAMA study, what's the incentive? I describe this phenomenon as "Death by p-value."
Tuesday, April 20, 2010
Monday, April 19, 2010
Sunday, April 18, 2010
What keeps sticking in my head is how little we've advanced since Semmelweis described the benefits of hand disinfection. For one, we're still doing quasi-experimental studies, although Semmelweis's design was at least controlled (midwives). It also seems that most of our contentious debates, including those around active detection and isolation, would be unnecessary if we'd followed his advice and had 100% hand hygiene. As for recent advances, the CLABSI checklist popularized by Peter Pronovost is probably the most important. Why was this advance made by someone who wasn't an ID physician or hospital epidemiologist? I think it's because as a profession we're stuck. Perhaps more clinical trials will advance things, but I have this suspicion we'll just end up proving what we already know - where will the advancement come from?
So, what does this have to do with the iPad? I just came across this article by Daniel Eran Dilger on how Steve Jobs utilizes creative destruction to change the world. The article is a little tech heavy and perhaps Apple biased, but I don't think that detracts from it's main points which I believe have relevance for a potential 'new' future for infection prevention. Dilger's main points are: (1) "Jobs understands death as a creative force better than most people. For society, culture, and technology to progress, old thinking has to die off to make way for fresh new ideas. People who don’t die are dragged kicking and screaming in the future..." and more importantly (2) "When something works, you don’t need to kill it. But in some cases you should."
So what does this mean for infection prevention and what should be "killed off"? I don't know. It's only been two weeks! However, I think we need to discuss what old ideas we are unnecessarily holding on to and we shouldn't back away from killing off things that work. Yes this is easier said than done and is perhaps a useless exercise. I'm just one guy, I don't even own a computer and I'm not even sure I know what a metaphor is.
Friday, April 16, 2010
Maryn McKenna, unfortunately, didn't get many words in but her comments around antibiotic stewardship in humans AND animals are very important. There is one point in the middle where Ira questions Ms. McCaughey's conflicts of interest around cleaning agents, listen for that. Near the end Ira brings up triclosan use in household products and Stuart Levy, having done much of the research on the harms associated with triclosan's use, offers a great description of why we should avoid it. Ira summarizing the discussion said that "we are going to devolve into the 18th century" where we won't have any effective antibiotics and "to me it sounds like you're just rearranging the chairs on the Titanic." Enjoy!
Direct audio link (here)
Website (here) with speaker info and audio link on the upper left side of the page
"We are concerned that any report coming from a government agency based solely on the use of administrative data, commonly referred to as billing/coding data, paints an inaccurate picture of healthcare-associated infections for the public. In contrast, another Department of Health and Human Services agency -- the Centers for Disease Control and Prevention (CDC) – is preparing to release epidemiologically sound, surveillance data based on the National Healthcare Safety Network (NHSN). Multiple studies have concluded that administrative coding data appears to be a poor tool for accurately identifying infections. This may create greater confusion among consumers."
Tuesday, April 13, 2010
I'm not sure where these data leave us and perhaps Mike, Dan and Connie will have some comments on this report too. However, I think what these data are telling us is that when you don't fund enough proper studies (and multiple studies) on methods to prevent HAIs - the 6th leading cause of death and when you are mostly left to resort to "absence of evidence-based medicine" tricks like kitchen-sink bundles...well, this is where you end up.
To suggest, as Katherine Sebelius did, that the new health care law would “help turn these numbers around” since hospitals with high rates of infections will be penalized starting in the 2015, is a bit hopeful. I think we haven't invested in HAI prevention studies like we have in cardiology and other areas, and I don't think we're going to get these rates down with sticks alone. You can't see in the dark if you don't know how to make a flashlight or even light a fire.
Monday, April 12, 2010
Photo: The Daily Mail
Sunday, April 11, 2010
Saturday, April 10, 2010
Just to emphasize how important the question of triclosan's safety is, it has been shown to persist in coastal waters for up to 40 years. Thus, we have a chemical agent, that was thought to be a non-specific and safe biocide, but has now been found in almost 50% of consumer soaps, select for resistant bacteria, potentially have hormone effects, persist in the environment and have little benefit to the consumer. The FDA will report back to us in Spring 2011.
The second study is from an academic medical center in Ireland with an occupancy rate of 105% (i.e., 5% of admitted patients are boarders in the Emergency Department awaiting ward beds). The authors sought to determine whether patients identified as previously colonized or infected with MRSA wait longer for a hospital bed once the decision to admit from the ED has been made. Patients previously identified as colonized or infected are flagged in the hospital information system as is done in many hospitals. Patients were who flagged waited 2.5 hours longer for a hospital bed than those who were not. Thus, crowding in Emergency Departments is exacerbated by a MRSA active surveillance program.
Although much of the debate on MRSA active surveillance focuses on whether the intervention is effective in reducing transmission of MRSA in the inpatient setting, that is only one of the important issues. Other important questions are whether the intensity of resources required by active detection and isolation (ADI) are merited to control this organism when other important pathogens are more common, and the adverse unintended consequences of ADI, as pointed out by these studies.
Thursday, April 8, 2010
Also check out Catherine Liu’s presentation on the new MRSA treatment guideline that is currently “in progress”. She delivered a great talk, and the PPT file is informative and useful.
Note: to open any of the presentations, you’ll have to click “read only” in the annoying pop-up window.
Wednesday, April 7, 2010
Anyway, Kikuchi disease is a rare disease with clinical features of diffuse lymphadenopathy and fever and 4:1 female predominance. It is often confused with lymphoma. The etiology is unknown but has been linked to EBV, HHV-6, HHV-8, Yersinia and toxoplasma. In a new case report in Pediatrics, authors in the UK discuss a case in a 15-year old boy associated with Pasteurella multocida bacteremia. I found it fascinating. The patient did well on antibiotics, especially considering that P. multocida bacteremia carries a 30% mortality rate.
Monday, April 5, 2010
Think about all of the money spent to track and then treat the contacts and cases in these outbreaks, and the needless suffering. It's too bad we can't charge those that intentionally don't vaccinate their kids if their kids spread disease. I'm not sure how you would do that. You have to pay taxes for fire and police and the army (mandated), you have to have auto insurance to drive a car and we may even need to have health insurance here soon, but you still don't have to get a measles vaccine to breathe on an infant!
Saturday, April 3, 2010
Friday, April 2, 2010
This little science experiment was performed as a result of reports we’ve received from another healthcare facility in our region that is having problems with hand rub ingestion using this method of emollient removal—a method that is now available on the interwebs for all to see. Others have reported problems related to hand rub ingestion, and I’ve read many of those reports—however, I was unaware of how easily one could render a disgusting gel into a potable alcohol solution. Here is an interesting report and description of one such use in a prison population, from a Clinical Toxicology meeting in 2006:
Hand Sanitizer Abuse
Roche KM, Barko IR, McDonagh J, Bayer MJ, Sangalli B. Connecticut Poison Control Center, UCONN Health Center, Farmington, CT, USA; Hartford Hospital, Hartford, CT, USA.
Background: Hand sanitizers are often gel-like emulsions, containing high concentrations (>60%) of ethanol. We became aware of correctional facility (CF) inmates using table salt (NaCl) to “break” these emulsions, to generate consumable ethanol. Therefore, a potential for abuse of these products by inmates and others exists. We sought to recreate this procedure and analyzed the resultant liquid for its alcohol concentration. We also surveyed the medical staff and corrections officers (staff) of the state's eighteen correctional facilities to assess their awareness of this practice. Methods: A) Following the method used by CF inmates, four ounces of hand sanitizer was added to a clean cotton sock that was placed over a glass graduated beaker. One teaspoon of NaCl was sprinkled on the gel-like material and within seconds a cloudy liquid filtered into the beaker. The resultant liquid was sent to an independent lab for alcohol analysis using a gas chromatography headspace technique. B) A telephone survey queried the CF staff of each facility (correctional officer (CO) supervisor and nurse) as to: 1) their awareness of this practice in their facility; 2) product availability to inmates, and 3) the value of this information towards changing their institution's policy regarding product availability. Results: A) Laboratory analysis revealed that the submitted liquid contained: ethanol 69.9% v/v; Isopropyl 2.1% v/v. B) Survey Results: 94% (17/18) of the CF staff were not aware of the potential abuse of these products. Inmates had direct access to product in 22% (4/18) of CFs. In one CF, product was removed from the cell blocks as a result of our survey. In 100% (18/18) of CFs, product is used in all medical areas as well as carried by correction officers. Discussion: CF staff found this information both enlightening and beneficial. Surveyed nurses planned on notifying their supervisors and the CO supervisors relayed that they would notify their staff. Conclusion: We discovered the potential for abuse of hand sanitizers in a number of state correctional facilities. More importantly we educated CF staff on the need to control product accessibility to inmates.
What does this mean for prevention? Besides keeping easily accessible products off units where abuse potential is high, education of staff should include awareness of the abuse potential, so that hand rub ingestion is considered when circumstances suggest it as a possibility (e.g. unexplained mental status changes, combined with higher than average product utilization!).