Tuesday, June 29, 2010

Cowboy hats always win? FDA nudges towards limiting antibiotics in animal feed

According to an article in today's NY Times, the FDA has just released a new policy limiting agricultural antibiotic uses to settings protecting animal health, and stating that veterinarians should be involved in the drugs’ uses. Various estimates suggest that between 13% and 70% of total antibiotic use occurs in agricultural settings solely to promote animal growth. These new changes may reduce slightly the amount of penicillins and tetracyclines used in animals. However, it is not clear that limiting "old" antibiotics such as these will have a large impact on MDR-bacteria in humans since it represents marginal use of antibiotics with resistance genes/mechanisms already circulating.

This quote from the article seems accurate: "In the battle between public health and agriculture, the guys with the cowboy hats generally win."

NY Times article (here)

Monday, June 28, 2010

Empowering patients to ask providers to wash their hands

"2000 miles
Is very far through the snow
I'll think of you
Wherever you go"
- Chrissie Hynde

We moved our family to Iowa City last week. There is something about being back in the Middle West that gets me singing old Pretenders' songs. I can't really explain it. One thing I've immediately noticed is that people say "hand washing" here and not "hand warshing" like I heard often back east.

Enough of that. There is a qualitative study out in the June issue of the Journal of Patient Safety by Amanda Garcia-Williams and colleagues from the CDC's DHQP that assessed the CDC video "Hand Hygiene Saves Lives" as a tool of patient empowerment. They conducted four focus groups using laypersons without hospital exposure in the past year, laypersons with hospital exposure, nurses and physicians. There are a lot of interesting findings within the study and many should be subject to further analysis.

The primary finding was that laypersons were much more likely to ask a nurse to wash his/her hands after watching the video, however, those with recent hospital exposure stated that they would still be "nervous" or "scared" to do so. Interestingly, laypersons with hospital exposure were more likely to ask physicians to wash their hands after watching the video but those without hospital exposure were not influenced by the video to ask physicians to wash their hands.

A very interesting finding was that laypersons with hospital exposure had lower levels of perceived risk for HAIs than persons who hadn't been in the hospital recently. Perhaps fear of the unknown is playing a role here. I suspect this fear could be used positively to get them to monitor compliance among their healthcare providers. Overall, I found the results of this study promising. Hopefully they will continue to analyze the impact of this video through quasi-experimental study or using other methods to see if this video intervention actually results in changed patient behavior, improved hand hygiene compliance, and dare I dream, reduced HAIs.

Article in the Journal of Patient Safety (here)

Friday, June 25, 2010

IV bactrim is gone

Hospitals across the country are facing a shortage of IV trimethoprim/sulfamethoxazole (bactrim). This is a severe shortage with hospitals reporting that they have completely exhausted all supplies. It is manufactured by a single company, Teva Pharmaceuticals, which is currently not able to project a date when it will be available. Moreover, the company has no supply to release for emergency use. Click here to view a nice table on therapeutic alternatives created by the American Society of Health System Pharmacists.

More than you'll ever want to know.....

For those of you interested in public reporting of healthcare associated infections, Pennsylvania has just released its 2009 report on HAIs. You can view it here. Since every HAI in every hospital is reported by mandate, this report represents the closest thing to a registry of HAIs that has ever been produced, and this report represents the first full year of reporting. There are 128 pages of slicing and dicing the data. In the 250 hospitals there were 26,000 HAIs across 11 million patient-days for an overall crude rate of 2.4 HAIs per 1,000 patient days. Surgical site infections accounted for 24%, UTIs accounted for 23%, BSIs accounted for 13%, and pneumonia cases accounted for 11% of the HAIs. Note that PA requires non-device related infections to be reported as well. Rates of infections were highest in academic medical centers and long-term acute care hospitals, as would be expected considering the patient populations served. Of note, MSRA accounted for 8% of all HAIs. Of the CLABSIs reported, 16% were due to Staph. aureus, 16% were due to coag-negative staph, and 14% were due to enterococci. One caveat: there has been no true validation of the surveillance at the hospitals though on-site audits are reported to begin this summer.

Thursday, June 24, 2010

We're good enough, we're smart enough, and doggone it, people like us!

Today's daily affirmation for infectious diseases doctors comes to us from Dave Warren's group at Washington University and is published in this month's American Journal of Medicine. In this study, the authors evaluated 341 cases of Staph. aureus bacteremia and compared outcomes between those patients who had an infectious diseases consult and those who didn't. Not at all surprising to any of us was that in multivariable analysis, patients who had ID consults had a 56% reduction in 28-day all-cause mortality, even though by most metrics the patients who had the consults were sicker. So when you start your rounds tomorrow consider yourself an independent predictor of good outcomes!

New CDC proposed guidance for influenza control

CDC recently posted proposed guidance on prevention of seasonal influenza in the healthcare setting. Written comments on the proposed standards will be accepted through July 22, 2010. The intent of these guidelines is to replace prior CDC infection control recommendations for seasonal and H1N1 influenza. In a nutshell, CDC is proposing droplet precautions, except when aerosol generating procedures are being performed, in which case airborne precautions should be followed. To see the document click here.

Pertussis outbreak

The LA Times reports today that pertussis activity in California has reached epidemic levels. To date this year, there have been over 900 confirmed cases with an additional 600 cases under investigation. Five deaths in infants have been reported.

Tuesday, June 22, 2010

Should we just skip SCIP?

There is a new paper and editorial on SCIP (Surgical Care Improvement Project) in this week's JAMA. SCIP is a Medicare project to improve compliance with practices that have been shown to reduce surgical site infections. These metrics include correct antimicrobial selection and timing, and appropriate hair removal. In this study the authors correlate compliance with SCIP metrics to surgical site infection rates, and the conclusion is that SCIP compliance doesn't correlate with reduction in SSIs. However, in my opinion, there's a huge problem with this study. The outcome data on SSIs were obtained using administrative data (ICD-9 codes), which are notoriously inaccurate. Kurt Stevenson showed that the positive predictive value of ICD-9 codes when compared to NHSN surveillance methods for 8 different categories of surgical site infections was as low as 14% and only as high as 51%. Thus, I don't think this study should sway our opinion about SCIP one way or the other. Since nearly all hospitals collect SCIP data and some states mandate NHSN SSI surveillance, the data should be available to replicate the study with better outcomes data. And if that shows similar findings, SCIP should be put to pasture.

Sunday, June 20, 2010

Health Care American Style

There are two new essays in the mainstream media that give excellent insights into problems with health care in the US. In today's New York Time's Magazine, there is an article entitled "What Broke My Father's Heart." It's the story of how modern medicine kept a severely demented man alive and it contains many lessons--that death is not always the worst fate a human can suffer, that more medical care is not necessarily better care, and that perverse incentives drive performance of procedures as opposed to thoughtful discussions of optimal care. The July issue of Harper's Magazine has a piece (subscription required), "How the Other Half Heals," by Teri Reynolds, an emergency medicine physician. She paints a realistic picture of life in the ED of a safety net hospital and vividly shows us how broken the system is for many.

Friday, June 18, 2010

Gawande's Velluvial Matrix

The New Yorker's website has posted Atul Gawande's recent commencement address to the graduates of Stanford Medical School. In his talk he describes great medicine as "work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either." It seems to me that this encapsulates the essence of our daily work in healthcare epidemiology.

Thursday, June 17, 2010

MRSA and survival in cystic fibrosis patients

Sorry for the slow down in posts, but my blogging will slow quite a bit for the next month. I had a bike mishap that has me wearing a big bulky splint on my right hand…this is slowing me down just as I prepare to start clinical service. I am learning that it isn’t easy to apply alcohol hand gels to just one hand, without using the other…a rinse would be better.

I did want to point out a study in this week’s JAMA on the association between respiratory tract MRSA carriage/infection and mortality in cystic fibrosis patients. We’ve discussed this before with respect to other papers that appear to show worse outcomes from MRSA than MSSA infection. Since we have no reason to believe that MRSA is intrinsically more virulent than MSSA, and since other such studies have been negative, how can we explain these findings? Less effective antibiotic therapy? Unmeasured confounders? I am tired of typing this post entirely with my left hand, so feel free to add your own theories in the comment section!

Sunday, June 13, 2010

Sunday reading

A couple recent New York Times articles relevant to infection prevention are worth a read. The first reports on an Annals of Internal Medicine paper describing how cost and reimbursement serve as barriers to the uptake of the adult varicella zoster virus (VZV, shingles) vaccine. The second is a fascinating story about the last of the old-time TB sanitariums. Although directly observed therapy (DOT) outside the hospital is the current model, there are some for whom prolonged inpatient care is needed, including those with dual diagnoses or extremely-drug resistant TB for whom simple outpatient DOT regimens are not feasible.

NY Times article on VZV vaccine
Annals paper describing barriers to vaccine uptake
NT Times article on A.G. Holley TB hospital

Wednesday, June 9, 2010

More infection control madness in the UK

At this point I've lost track of stupid new rules in UK hospitals enacted in the name of infection control. But here's the latest: reducing visiting hours for new fathers. A local newspaper editorial asks the critical question: "What we fail to see is that if a father who is carrying germs is on the ward what difference does the length of time they spend there make?" 

This is just another example of what happens when the goal of infection control policy is PR instead of infection control.

Tuesday, June 8, 2010

LRSA Outbreak II: The sequel

Another linezolid-resistant Staphylococcus aureus (LRSA) outbreak is described in this week’s JAMA. Eli posted a few months ago about the other outbreak, also in Spain, reported in Clinical Infectious Diseases (CID). The similarities between the two outbreaks are stunning, so please just check out Eli’s post for the most important take-home points about cfr-mediated linezolid resistance in staphylococci.

Hey, wait a minute....I think I know why these outbreaks seem so similar. The two papers report on the same outbreak. You wouldn’t know that right off the bat, because neither paper references the other. {see addendum below}

While I applaud the authors for adhering to the least publishable unit (LPU) concept that I hold so dear, I must reluctantly conclude that this is inappropriate. It was an ICU outbreak that involved 12 infections, and the authors should have been able to describe it in one paper. Before I detected the dual publication, I kept looking through the results and figures in the JAMA paper for more detail on some of the microbiology. The reason I didn’t find it was because it was all in the CID paper….

What additional information can we glean from the JAMA paper? In no particular order, we learn that this hospital had an aggressive MRSA active surveillance and decolonization program (but it’s still rife with MRSA and suffered the first big ICU outbreak of LRSA, which definitely proves something about active surveillance, I’m just not sure what); we learn that they did a whole bunch of environmental and hand cultures, only one of which was positive for LRSA (a single environmental culture, but wait, that was also reported in CID); we learn that they recognized the outbreak, did a bunch of stuff we always do when outbreaks occur, the outbreak went away, and no one is quite sure what all happened. Standard issue hospital infection prevention, in other words.

ADDENDUM: On first read I missed the fact that the authors actually did reference the earlier CID report in the JAMA paper--my apologies. I stand by my comment that the outbreak could and should have been reported in full in one manuscript, but at least the careful reader (which clearly doesn't describe me!) should be able to find his/her way to the additional details (mostly micro related) in the CID piece.

Eli's post
JAMA paper
CID paper

Infection control in ambulatory surgery centers

This week's JAMA has a paper on infection control in ambulatory surgery centers. Given the volume of procedures performed in these facilities (>6 million yearly), the recent outbreaks of hepatitis that have been associated with ASCs, and the fact that many are truly freestanding, the topic is important. But all in all, I didn't learn much from this paper. Sixty-eight ASCs in 3 states were surveyed using an audit tool, and at least 1 tracer (following a patient through the continuum of care) was done at each facility. While the tracer methodology is the standard used by The Joint Commission during its on-site audits, can we really infer the quality of care in an organization that cares for thousands of patients yearly on the basis of a handful (at most) patients? Similarly, for all areas of the audit, the assessment was all-or-none with no attempt to quantify anything less than perfect compliance. So with regards to assessing hand hygiene, a single observed noncompliant episode was graded the same as 0% compliance. Most concerning was that in 1 center prefilled syringes and infusion sets were used for more than one patient, though in no centers was there any observed reuse of needles or use of contaminated needles to draw from a medication vial used for more than one patient. It would be interesting to know how the results differ from the same process used to audit hospitals. The author of the paper's editorial seemed to struggle with what to say (understandably), with only 2 paragraphs related to the results of the paper. So in the end we have a study that reflects the audit process that's typical of that used in the real world, but we're left with asking what it all means.


Eli recently posted a piece on a study by Nicholas Christakis and James Fowler that looked at the spread of influenza in social networks. I'm currently reading their book, Connected, which explores many issues regarding social networks. It's an interesting read, particularly the chapter on how these networks influence health, including the contagion of obesity and suicide, and the complexity of transmission of sexually transmitted diseases. They also note how social networks could be exploited to improve health. Here's one interesting way: it's possible to achieve the effect of randomly vaccinating 99% of individuals in a population by vaccinating only 30% of the acquaintances of randomly selected individuals. There's also a TED talk on social networks by Christakis here. Lots of food for thought.

Saturday, June 5, 2010

Dissonance, the hyperlink and blogs

“Learning how to think, means being conscious and aware enough to choose what you pay attention to and to choose how you construct meaning from experience.” - David Foster Wallace

I've been meaning to write about this all week, but I got distracted. I was probably reading about where LeBron James is headed and clicked on some links, ended up reading about the Cubs then the Illinois Senate race, then the South Carolina Governor race...you get my point. Nicholas Carr's latest book “The Shallows: What the Internet Is Doing to Our Brains,” has just arrived on bookshelves and he has posed some interesting questions, some of which I think relate to how we use or perhaps should use the internet to communicate. A major question he poses is if links should be listed at the end of web posts. Carr credits Steve Gillmor, who eliminated hyperlinks from his posts a few years ago, with starting this crusade, which is apparently starting to catch on, and with good reason. Have you noticed how hard it is to NOT click on a link in the middle of a post? Do you ever even finish one of our posts before ending up in some far-away place and forgetting how you got there and even forgetting that conference call that you were supposed to be on 15 minutes ago. Me neither.

Carr describes links as "...tiny distractions, little textual gnats buzzing around your head. Even if you don't click on a link, your eyes notice it, and your frontal cortex has to fire up a bunch of neurons to decide whether to click or not. You may not notice the little extra cognitive load placed on your brain, but it's there and it matters. People who read hypertext comprehend and learn less, studies show, than those who read the same material in printed form. The more links in a piece of writing, the bigger the hit on comprehension." So what to do? The general feeling is that links should be listed at the end of the text. This allows you to calmly read through the post and THEN decide which primary, or at least non-tertiary, sources you would like to review. I think it's a good idea. Cheers.

New York Times Sunday Book Review of Carr's new book
New York Times Nicholas Carr Q&A
Carr's original blogpost on the subject
Link to Amazon's DFW "Infinite Jest" page (What Carr is Reading)
Link to Amazon's DFW "Brief Interviews with Hideous Men" (What I'm reading) - "Forever Overhead" - wow

Friday, June 4, 2010

WHO exaggerated H1N1 Threat, Potential COI issues

Two separate European reports criticized the WHO for exaggerating the H1N1 threat and failing to disclose pharmaceutical conflicts of interest. The first report was from the Health and Family Affairs Committee of the Parliamentary Assembly of the Council of Europe (say that three times) and looked at the pandemic response and the second was from BMJ and the Bureau of Investigative Journalism and looked at the 2004 guidelines which were written by three experts with financial ties to Roche and GlaxoSmithKline. Washington Post article (here), BMJ+BIJ (here), Council of Europe article (here) and pdf of Council of Europe report (here). I wonder if N95 manufacturers are getting nervous?

Thursday, June 3, 2010

Extreme public reporting

The UK has taken public reporting of HAIs to a new (and absurd) level. The NHS website now publishes weekly counts of hospital-acquired MRSA bloodstream infection and C. difficile cases for every hospital in the country. You can see it here in an excel spreadsheet. Now I happen to think that transparency and accountability are vital concerns, but I also think that publicly reported data should have utility. As a hospital epidemiologist with two decades of experience, I don't know what to make of these data, so how could the average healthcare consumer? Because of the stochastic nature of HAIs, the frequency counts for any given week are useless, not to mention there is no risk adjustment provided. Yet there seems to be an implicit association of these data with quality of care, and this is another example of perception trumping reality in infection control. What's next--Twitter alerts for every new C. diff case in the country?