Thursday, October 28, 2010

Labyrinth of Terror

Many of the readers of this blog may be interested to know that Dick Wenzel has just published his first novel, Labyrinth of Terror. I just finished reading it and recommend it highly. It's not everyday that those of us who work in infection prevention can read a novel that deals with our world, but here's your chance. The story is set in London and the protagonist is an American hospital epidemiologist who helps a British colleague with an outbreak of healthcare associated infections in a London hospital. The book is fast paced, immediately drew me in, and was a very fun read. You can order it here.

Wednesday, October 27, 2010

The impact factor & the almighty dollar

Since the inception of this blog, we have written frequently about conflict of interest, and it seems as though new types of conflicts continue to be uncovered. There's an interesting new paper and editorial in PLoS Medicine on how industry supported clinical trials affect a journal's impact factor. The authors reviewed randomized trials in 6 major journals, including JAMA and the New England Journal of Medicine. They found that industry supported trials had more citations than those not funded by industry. What I didn't know was that "non-citable" papers (editorials, news pieces, and letters to the editor) are included in the numerator but not the denominator of the impact factor calculation. For the New England Journal, removing the non-citable pieces would lower its impact factor by 24%. So there is a conflict of interest at play here: the publication of industry-funded trials not only increases the journals' impact factors, but the journals also make money by publishing reprints. For example, nearly half of Lancet's income is derived by selling reprints. As the editorial points out, the journals have greatly increased their scrutiny of authors' conflicts of interest, but the journals and their parent organizations may not be holding themselves to the same standards.

In the Atlantic Monthly

In the November Atlantic Monthly the cover story is on 19 brave thinkers for 2010. The first of these is Dr. John Ioannidis, a Harvard-trained physician epidemiologist, who chairs the Department of Hygiene and Epidemiology at the University of Ioannina, Greece. He is probably most famous for a paper he published in 2005, Why Most Published Research Findings are False. The paper has been downloaded nearly 300,000 times. He believes that 80% of non-randomized studies have incorrect conclusions, as do up to 25% of randomized trials. The Atlantic's profile of Ioannidis can be viewed here.

In the same issue, there's also a piece on the demise of the wristwatch. I haven't worn a wristwatch since I embraced bare below the elbows 2 years ago. Losing the watch was a sacrifice for the sake of infection prevention, but I have to admit I don't miss it at all. According to the article, watchmakers are developing apps for mechanical watches (called complications) to try to maintain consumer's interest in them, but the author predicts that watches will go the way of the sundial.

Holy Superlatives, Batman! Hospital-acquired infections have significant economic costs!

1935 Dollar

There is a well done study out in Medical Care by Rebecca Roberts et al. from Stroger/Cook County that assesses the attributable costs of HAIs in a cohort of patients from 2000.  What sets this paper apart is the careful attention they paid to design and analysis methodology.  Just to paste from the abstract, they used "ordinary least squares linear regression and median quantile regression, Winsorizing, propensity score case matching, attributable LOS multiplied by mean daily cost, semi-log transformation, and generalized linear modeling. Three-state proportional hazards modeling was also used for LOS estimation. Attributable mortality was estimated using logistic regression." 

Tuesday, October 26, 2010

Quality, safety, and value

There is an interesting commentary in JAMA this week. The money quote:

“So more than 40 years after the birth of the quality improvement movement, there is still not much known about what has been accomplished.”
The author, Robert Brook, argues for embracing the business case for quality, and for developing a new “epidemiology of value”,

“…which contains both measurement of cost and quality, and is applicable to both the developed and developing world. The results of this work would help to distinguish between a level of quality that is a good value and the best available quality that may produce small improvements in health at enormous cost.”
Eli, as our house economist, has a better grasp of what it takes to build a business case for quality…I should let him take it from here…

Monday, October 25, 2010


…will bring up the “Find and Replace” tool in Microsoft Word. Illinois legislators, you may want to use this tool today, so you can get yourselves a shiny new law to deal with the latest emerging antimicrobial resistance threat.

Hint: you’ll want to find “MRSA”, and replace with “KPC”. Make sure to go to “search options” and click on “Match Case”, or you’ll mess it all up.

That should do it.

Illinois screening legislation
IDSA abstract on emergence of KPC-producers in Illinois
Chicago Tribune story

Sunday, October 24, 2010

Cholera in Haiti

A horrendous development, poised to get much worse if the epidemic begins spreading in Port-au-Prince. The preconditions for a massive outbreak are present, namely limited access to safe potable water and proper sanitation, both of which require an intact infrastructure. Over a million people are still living in tent camps around Port-au-Prince, with minimal or no sanitation.
While media attention is appropriately focused on Haiti, this should also serve as a reminder that cholera outbreaks occur regularly throughout the world, most commonly in sub-Saharan Africa, where Nigeria is now in the midst of a huge outbreak. These outbreaks typically receive very little media attention.

Saturday, October 23, 2010

Been down so long...

being down don't bother me.  Having spent a few days here in Vancouver, I'm reminded of a paper published earlier this year out of British Columbia.  Gill et al, reported in CID results of a large 5422 person cohort of HIV+ patients with resistance testing during 1996-2008.  They described a drastic decrease in the incidence of new cases of HIV-1 drug resistance with the incidence rate of any newly detected resistance falling 12-fold from 1.73 cases per 100 person-months of therapy in 1997 to 0.13 cases per 100 person-months in 2008. I have posted Figure 1B below from the paper which shows declines in resistance to the major antiretroviral classes (PI, NRTI, NNRTI).

Friday, October 22, 2010

How many times must a....

....patient test negative for Clostridium difficile, before you can call him negative? The new PCR assays for toxin B detection are more sensitive, and therefore have higher negative predictive values, than the older enzyme immunoassays. And even for the EIAs, the data to support the common practice of sending “C. diff X 3” were pretty weak.

A simple retrospective study in the October Journal of Clinical Microbiology shows how low-yield a repeat C. difficile PCR is, when ordered within 7 days of a negative test. Among almost 300 patients with a negative test who were re-tested, only 10 positive results were obtained. One was a false positive (compared with gold standard cytotoxicity assay), and 7 of the remaining 9 were positive more than 7 days after the first test (and usually in the context of ongoing risk factors for C. difficile, or new onset of diarrhea).

If your lab uses PCR for C. difficile toxin detection, save money and time by abandoning the practice of sending repeated tests to "rule out C. diff".

Thursday, October 21, 2010

Are we ready to kill contact precautions?

Pauline Chen, in her New York Times column, Doctor and Patient, takes on contact precautions this week. Her piece, When Isolation Hampers More than Bacteria, is one of the first in the mainstream media to point out the unintended consequences of contact precautions. This has been a recurring theme on our blog. In one of the very first postings on this blog, Dan wrote a piece entitled, Why I hate contact precautions. Just this week I was asked by a concerned medical student to review the case of an elderly man hospitalized for over 3 months and confined to a lonely hospital room because a nasal swab grew MRSA. "Can't we just allow him to sit in the hallway?" asked the student. And we figured out a way to do that. Dan Morgan states in Chen's piece: “There is a misperception that infections are the single worst adverse event that can happen in a hospital.”  Also quoted in the piece is my colleague, Gonzalo Bearman, regarding our studies comparing universal gloving and contact precautions, which found no difference in infection rates when the two strategies were compared. Maybe it's finally time to think about moving beyond contact precautions.

Improving QI

Sean Berenholtz and colleagues have a nice commentary/review piece in this month’s Joint Commission Journal on Quality and Patient Safety that touches again on the tension between quality improvement and the science of healthcare epidemiology. They start with an anecdote about the presentation of a QI project at a patient safety meeting, during which many important potential biases and limitations were not mentioned. To quote directly from the piece:
"When an audience member questioned the validity of the results, the presenter clarified that the data were for “quality improvement” not “research,” implying, as stated earlier, that QI projects are exempt from the rigorous methodological standards required of other research projects. In our experience, such views are widely promulgated among QI practitioners."
The rest of the piece reviews basic concepts in study design and interpretation, and includes a useful checklist for evaluating QI projects.

The piece also does a good job of succinctly arguing the importance of rigorous standards for QI, and the potential unintended consequences of accepting and disseminating practices that are based upon inaccurate data and/or flawed study designs.
"Overestimates of the extent to which harm is preventable may anchor policymakers’ beliefs and create potentially unjust and unwise policies."

True, that.

Mike's recent post on QI vs. Healthcare Epidemiology

Joint Commission Journal article (subscription required for access)

Wednesday, October 20, 2010

Garbage makers

Slate has a piece on the environmental impact of hospitals, including the trash produced. This isn't something we hear much about. Money quote:  "Hospitals don't just produce a lot of garbage; they produce fantastically complicated garbage." The author decided to investigate the topic after her son was hospitalized and she noticed the large volume of trash coming from his room. It's worth reading. 

Tuesday, October 19, 2010

Happy Weekend: Early Edition - Deer Tick in Vancouver

For those of you lucky enough to be heading to IDSA in Vancouver this week, there is an overlapping event that might interest you.  Deer Tick is playing at the Vancouver Biltmore this Friday, October 22 at 9:30pm PDT, which is only like 6:30pm EDT. (this was a joke) Why would you care about Deer Tick? Great music and they were named by lead John McCauley after taking a hike in Indiana with his good friend and discovering a deer tick on his scalp later that evening. No word on his lyme status. Enjoy Baltimore Blues No 1 and Vancouver.

Monday, October 18, 2010

New glycopeptide resistance gene cluster (VanM) found in E. faecium

Originally recovered in 2006 from a Shanghai patient with an intra-abdominal infection, the new Enterococcus faecium was highly resistant to Vancomycin(MIC, >256 µg/ml) and teicoplanin (MIC, 96 µg/ml).  The novel vanM cluster shares a similar DNA sequence to vanA, but is arranged more like vanD. At least the VanM, like VanA, confers glycopeptide resistance by the inducible synthesis of precursor ending in D-Ala-D-Lac. One less thing to learn. So now we have to remember vanA, vanB, vanC, vanD, vanE, vanG, vanL and vanM. The enterococcus sure has been busy making new VREs.

November 2010 AAC article Xu X., et al.

Happy International Infection Prevention Week (Oct 17-23)

October has been a busy month. I hope you all have recovered from World MRSA Day and Global Handwashing Day. I haven't, but I still wanted to remind you all to celebrate International Infection Prevention Week in style.  I also wanted to give you all a hug. One of those hugs where we kinda hug the air and don't actually touch each other. Touching wouldn't be very infection preventiony now would it.

Sunday, October 17, 2010

I love me some magic!

There's an entertaining essay, Magic by Numbers, in today's New York Times. It's written by a psychologist who asks why we treat infections for durations of time that seem arbitrary (like 7 days). As an infectious diseases doctor, I must admit that duration of antibiotic therapy is one of the most common questions I am asked, and one for which there are few data. I sometimes preface my response to the how-long-to-treat question with, "I'm just making this up," and then pontificate with something like, "but I would treat for 10-14 days." And the intern dutifully enters an order for a 10-day course of vancomycin if the patient needs to stay in the hospital to receive it, or 14 days if the patient can receive IV antibiotics at home. The author of the essay, Daniel Gilbert, nails it when he writes that magic numbers "hold special significance for terrestrial mammals with hands and watches, but they mean nothing to streptococcus." Uh-oh! Our erudite approach has been exposed as nothing more than magical thinking. But there's a lot of magical thinking in medicine. Here are a few examples that come to mind: Wearing a white coat makes a doctor more professional. White coats worn daily for months without washing couldn't possibly be involved in transmitting bacteria to patients. The only way to control MRSA in the hospital is by culturing every patient for MRSA and isolating those that are colonized. And my current favorite: influenza vaccine is so effective that we should fire healthcare workers who don't get one (here's a new paper on that topic).

P.S. Here's a video of a great TED talk on impact bias and synthetic happiness by Dan Gilbert.

Thursday, October 14, 2010

Stay home!

Mike has posted several times recently on presenteeism, a problem that is long overdue for increased attention. At a time when more and more healthcare workers are at risk for termination should they not get their flu shots, why are we not taking presenteeism more seriously? It seems like a much greater threat to our patients than is an 86% influenza vaccination rate (the rate we achieved here without a mandate). Today’s NY Times has an excellent piece by Dr. Pauline Chen, describing her personal experience and discussing the Journal of General Internal Medicine paper that Mike blogged about previously. I’ll end with this quote from Dr. Chen’s article:
“......when doctors come into work so sick they need intravenous fluids, it’s considered a badge of courage,” said Dr. Eric Widera, the study’s lead author and an assistant professor of geriatrics at the University of California, San Francisco. “No one is standing up for the patient and saying, ‘This is wrong.’ ”

Mike's previous posts on presenteeism
The JGIM paper (pdf)
Dr. Chen's NY Times article

Global Handwashing Day

Only 13 or so hours (depending on your time zone) to the third annual Global Handwashing Day,which occurs October 15, 2010. This should not be confused with World Hand Hygiene Day, which occurred May 5, 2010 or even World MRSA Day or for those of you really in the know, "MDR-Acinetobacter Day," which occurred on Oct.4.2010.  All kidding aside, tomorrow is an important day to recognize the lack of access to basic soap and water that many children in the developing world need to prevent illness and death.  This day is for the children.

The graph below, from a 2005 Lancet paper by Luby et al., highlights why tomorrow is so important.  In Karachi Pakistan's squatter settlements, investigators randomized 300 households to plain soap/water, 300 to antibacterial soap and 306 to usual practice.  Both groups randomized to soap (antibacterial soap didn't matter) had 50% less pneumonia, 53% less diarrhea and 34% less impetigo compared to the control group. This day tomorrow is about making sure each child is on the green (or red) line and not suffering on the blue line.

Luby et al, Lancet 2005 doi link

Wednesday, October 13, 2010

Everybody loves a good argument

A Journal of Clinical Microbiology editor just sent me the download statistics for their new "point-counterpoint" feature. The format is extremely popular, and I was happy to learn how many people have downloaded the MRSA screening piece that Lance Peterson and I published in March. For ASM journals, there is free access once an article has been in publication for more than six feel free to download it, in pdf or html format.

Bacteria can walk?---Whoa, Nellie!---Bacteria can walk!

Image Credit: Gerard Wong, UCLA
Well, I knew there had to be an explanation.  It couldn't be that bacteria spread from patient to patient because hand hygiene compliance is only 60%.  No, it can't be our fault.  Now, there is finally data for surgeons to use when they say they're too busy to wash their hands.  They can just say that the bacteria will just walk to the next patient room anyway, so why bother.  Well, maybe not exactly...

There is a new study out in Science from scientists at UCLA, Houston, Illinois and Notre Dame that identified a new surface motility mechanism in Pseudomonas aeruginosa whereby they were able to stand upright and "walk" in a verticle orientation. This was thought to allow for surface exploration, improve surface detachment and perhaps enhance biofilm formation.

So maybe washing our hands makes them too slippery for bacteria to walk on and they just trip?  OK, I just made that up. Anyway, it probably remains a good idea to perform proper hand hygiene.

Gibiansky et al. Science 8 October 2010

h/t: ars technica, Nobel Intent post

Tuesday, October 12, 2010

How important is the physical exam?

Most of us do parts of it each time we care for a patient. Aspects of the physical exam are included in several of our nosocomial infection definitions. Yet how good are we at performing physical exams anymore? How reproducible and reliable are physical findings (within and between observers)? How sensitive and specific for diagnosing illness, including infection?

I'll admit I've sometimes thought (usually when frustrated over low hand hygiene adherence) that patients would be safer if healthcare workers didn't touch them at all.

If this topic interests you, today's NY Times has an article on Dr. Abraham Verghese, who is passionate about "taking back" the lost art of the physical exam.

Sunday, October 10, 2010

SHEA's white paper on elimination of healthcare associated infections

Eli asked me to take on the daunting task of posting on SHEA's new white paper, Moving toward Elimination of Healthcare-Associated Infections: A Call to Action. So I read it. Well, at least part of it. I didn't think I could do it justice, so I asked two of the country's leading experts to make a video for our readers. This video will tell you everything you need to know. Click here to view it.

Saturday, October 9, 2010

Happy Weekend: Didier Pittet on Yesterday and Tomorrow's Heroes

Do you have any time left?  Yesterday I posted Günter Kampf's talk on hand hygiene from Medline's third annual conference called Prevention Above All.  Today we have Didier Pittet speaking on Preventing Healthcare-Associated Infections: Pioneers of Yesterday - Heroes of Tomorrow.  Lot's of history: Florence Nightingale and Ignaz Semmelweis. Enjoy

Friday, October 8, 2010

Happy Weekend: Günter Kampf on Hand Hygiene

It's the weekend, so you have some time, right? Medline recently held their third annual conference called Prevention Above All, August 16-17, 2010. Günter Kampf, MD speaks on Hand Hygiene Strategies: Challenging the Status Quo, which may be of interest to you. The list of speakers is impressive, including Atul Gawande.  Tomorrow, I will post Didier Pittet's talk.  This is part 1 of 6, just click on the next section when the part finishes to hear the whole talk. Enjoy.

Thursday, October 7, 2010

2009 H1N1 Pandemic Response: Looking backward and forward

Recently in PLoS Medicine, Gabriel M. Leung from the Food and Health Bureau, Hong Kong and Angus Nicoll from the European Centre for Disease Prevention and Control reflected on the public health response to pandemic H1N1. They discuss what went right and what should be done now to augment our future responses.

I really liked that their primary points highlighted that "public health messages...should not confuse what could happen (and should be prepared for) with what is most likely to happen" and that "decisions regarding pandemic response during the exigencies of a public health emergency must be judged according to the best evidence available at the time."  I've pasted below the list of pandemic "Firsts" which included a special shout out to the challenging "blogosphere," of which this here ye olde blogge was a member.

Box 1. A Series of “Firsts” about Pandemic (H1N1) 2009

  • The first pandemic to emerge in the twenty-first century. It has been more widespread and remains ongoing, compared to SARS.
  • The first pandemic to occur after major global investments in pandemic preparedness had been initiated.
  • The first pandemic for which effective vaccines and antivirals were widely available in many countries, thus requiring public health authorities to earn and retain the confidence of health care providers through whom such are usually distributed.
  • The first influenza pandemic to coincide with the ongoing HIV/AIDS pandemic and for which preliminary data do not suggest a substantial, disproportionate impact on HIV-infected patients.
  • The first pandemic that took place within the context of a set of International Health Regulations and global governance, which had not been widely tested until the present.
  • The first pandemic with early diagnostic tests that led to rapid diagnosis but also an early obsession in the media and of policymakers with having reports of the numbers of those infected.
  • The first pandemic with antivirals available in many countries that led to a hopeful expectation that the pandemic might be containable, leading to the preparation for and implementation of a “containment phase” in some places.
  • The first pandemic in which intensive care was available in many countries to treat critically ill patients, fostering an expectation that everyone could be treated and cured.
  • The first pandemic with instant communication so that early impressions (such as the experience and response in Mexico and the Ukraine) could be shared ahead of proper scientific analysis.
  • The first pandemic in which web-based platforms of traditional journals expedited dissemination, complemented by other innovative online resources (e.g. PLoS Currents: Influenza,​nfluenza#, based on Google's knol technology).
  • The first pandemic with a “blogosphere” and other rapid social media messaging tools that challenged conventional public health communication.

Wednesday, October 6, 2010

Putting the "or" back in your org chart

Having trouble figuring out how to reward and promote people within your department, hospital, or infection prevention program? Maybe you should try this. Playing off the age-old Peter principle (that every new member of an organization eventually is promoted to his/her level of incompetence), these investigators use game theory to demonstrate that the best way to improve organizational efficiency is to promote people at random.

Monday, October 4, 2010

The History of Vaccines (new website)

The College of Physicians of Philadelphia, the oldest professional society in the United States, has just launched a new educational website on the History of Vaccines. There is so much information available, that it literally will blow your mind. I should post a picture, it's not pretty. Topics include "The Development of the Immunization Schedule," a timeline of vaccination history from the year 1000, "History of the anti-Vaccination Movements," and "Top 20 Questions about Vaccines." There are already 424 images and videos for your use and education. Wow.

The site has been planned for several years and has been in development for a year. It will officially launch on November 3, 2010, when Stanley A. Plotkin, MD, developer of the current rubella vaccine, and emeritus professor of The Wistar Institute and The University of Pennsylvania, will give the Samuel X Radbill lecture entitled "Four Centuries of Vaccinology" in Philadelphia.

Check out the preview version of the website "The History of Vaccines" and related blog. Just fantastic.

h/t Tara Smith at Aetiology

Saturday, October 2, 2010

Happy World MRSA Day (10.2.10)

The World as seen on World MRSA Day
I hope you guys are all out celebrating/observing World MRSA Day.  It's pretty quiet around here, well, except for the Penn State-Iowa game tailgating.  Go Hawkeyes! and, ah, go wash your hands...

Swine flu & conflict of interest

There is an interesting editorial in this month's Journal of Public Health that looks at conflicts of interest with regards to the swine flu pandemic. The author briefly describes some examples of organizations that manage financial and intellectual conflicts quite well. It's worth reading and the full text can be viewed here.

Friday, October 1, 2010

In it to win it

Good news going into the weekend: the CDC just declared Healthcare Associated Infections (HAIs) to be one of their first six “Winnable Battles”. They have coined this term to describe “public health priorities with large-scale impact on health and with known, effective strategies to intervene.”

I hope this leads to more resources—not just for implementation but for novel prevention research. As we’ve pointed out before, there is more than one view of what it means to “win” the war on HAIs. By one assessment, we already know how to prevent HAIs. All we need to do is implement this knowledge and such infections will drop to zero (and if they don’t, we can finesse the definitions until they do!). A more nuanced view is that our current prevention strategies are effective, but only against the subset of infections those strategies target. That is, there are still infections that cause harm and for which we do not currently have effective prevention strategies. These differences in perspective are also well illustrated by Mike’s earlier post on hospital epidemiology and quality improvement.

Where you fall on this continuum makes a big difference in terms of where you’d like to see more resources. Should they be devoted primarily to implementation of existing strategies (and to “implementation science”), or to research addressing novel approaches to infection prevention? (I realize that the correct answer is "both". But resources, sadly, are not infinite)

*motivational poster image courtesy of Despair, Inc.

Happy Weekend: VALORI or Volaré?

Remember those 1979 Plymouth Volaré ads?  Remember how the Volaré was the car that brought bankruptcy Chrysler's way?  Me neither.  Well, when I see the the acronym VALORI (Ventilator Associated Lower Respiratory Infection) like in Dan's recent VALORI post, I start singing Volare in my head.  Now, perhaps, the same thing will happen to you. For that, I'm truly sorry. To apologize, I bring you Dean Martin, the pride of Steubenville, Ohio.