Tuesday, November 30, 2010

Woo woo! Senate passes FDA Food Safety Modernization Act

Thanks Senator Harkin
Not too much to say, that I haven't said before. Today the Senate passed the FSMA bill 73-25-2. This bill was actually introduced in March 2009 and would cover 80% of the food supply excluding meats. This seems like a nice example of bipartisanship. The NY Times mentioned that Republican and Democratic Senate staffers met for the first time in ages and 'broke bread' with Starbursts and jelly beans. Let's hope this gets out of committee in time or is simply passed by the House as is. Would be sad to see this die when the clock runs out.

Final quote: “This legislation means that parents who tell their kids to eat their spinach can be assured that it won’t make them sick,” - Senator Tom Harkin (D-Iowa)  Of course, anyone who needs to figure out how to get their kids to EAT their spinach, should check out my friends Laura and Jennifer's book from the American Academy of Pediatrics: Food Fights: Winning the Nutritional Challenges of Parenthood Armed with Insight, Humor, and a Bottle of Ketchup

NY Times article 11/30/2010

Sunday, November 28, 2010

Don't pull that trigger!

The headline on the front page of the New York Times this week read "Study Finds No Progress in Safety at Hospitals." This article (graphic shown) reported on a paper in this week's New England Journal of Medicine (free text here). In this study, 240 charts from each of 10 hospitals in North Carolina were reviewed using the Institute for Healthcare Improvement's (IHI) Global Trigger Tool. The admissions reviewed spanned the years 2002 to 2007.

Now I didn't know much about the Trigger Tool and the methods section of the paper doesn't give much description, so I looked up the guide, which you can review here. The triggers are 53 different indicators that when observed in the medical record should prompt further review to assess for an adverse event. For example, administration of benadryl is a trigger to look for a drug allergy, which according to IHI is an adverse event. Adverse events are further classified by severity and whether they were preventable. Per the IHI guide, no more than 20 minutes can be spent on the review of any chart (that rule was also observed for the published study).

Per the IHI methodology, healthcare-associated infections are both a trigger and an adverse event. Here is what the guide states (p.17):
Any infection occurring after admission to the hospital is likely an adverse event, especially those related to procedures or devices. Infections that cause admission to the hospital should be reviewed to determine whether they are related to medical care (e.g., prior procedure, urinary catheter at home or in long-term care) versus naturally occurring disease (e.g., community-acquired pneumonia).
Note that HAIs are never defined. Unlike the CDC's National Healthcare Safety Network (NHSN), which defines infections using multiple data points, IHI methodology doesn't guide the reviewer as to case ascertainment. I did a PubMed search this morning and found no studies where the Trigger Tool was compared to NHSN methodology to assess its validity.

So here are some concerns I have about this paper and the Trigger Tool:

  • By design the Trigger Tool is not true surveillance. There is no attempt to detect all instances of harm. Imagine looking at the medical record of a patient who stayed in the hospital for 8 months with a 20-minute time limit. While I can understand how the Trigger Tool might uncover problems in any given hospital using a case-based approach for quality improvement, to look for trends over time using these data doesn't make any sense since there is no attempt to capture all the cases of harm. Of what value is trending incomplete data? I think this harkens back to the philosophical differences between quality improvement and healthcare epidemiology that I've talked about before
  • I have serious concerns regarding the validity of this approach for HAIs. We know how problematic surveillance can be even when using well-delineated case definitions and how poorly administrative claims data perform for HAIs. The IHI approach seems much more analogous to the administrative data approach.
  • In the New England Journal paper the secular trends were shown only for all harms and preventable harms, but not for any of the component harms, such as HAIs. It would be interesting to see the trended data for HAIs. Recall that AHRQ, using administrative claims data, recently published a paper claiming that HAIs are increasing in the US, while CDC, using much more rigorous surveillance methodology, published the opposite conclusion.
  • Generalizability seems to be problematic. In this paper 2,400 hospital records were reviewed from 10 hospitals in a single state. Over the same time period, there were approximately 220 million hospital admissions in the US. That means that about 1 in 100,000 hospital admissions were reviewed (and only partially given the 20-minute rule). While the published paper never attempts to generalize the study findings to the universe of US hospitals, the media certainly did, and the lead author of the study states in the New York Times, “It is unlikely that other regions of the country have fared better.”
  • Some of the instances of "harm" are not preventable and I'm not sure how they are related to quality of care. For example, consider the case of a patient with no known drug allergy who is treated with an antibiotic and develops a rash. This would be classified as a harm, and it is indeed a harm to the patient, but it's not predictable and not preventable. How does it help us to trend such data? And how would we attempt to reduce this harm? It is preventable harm that needs our attention. 
  • With regards to HAIs, even if these data were valid, I don't believe these data reflect the current state of affairs in US hospitals given that much improvement in infection rates has occurred since 2007.
So here we have another paper that beats us up some more. If truth be told, I bet that the quality of care in US hospitals is significantly better today than it was in 2002. It sure would be nice to see that in print, but it probably wouldn't hit the front page. 

P.S. It's amazing that IHI claimed to have saved 123,000 lives in the US due to its safety program for US hospitals, but now claims that during the same time frame there was little evidence of improvement in patient safety. Something doesn't compute......  

Saturday, November 27, 2010

PEP, PrEP, or even PeEP?

I finally got around to reading the paper in the New England Journal on the use of daily antiretroviral therapy for the prevention of HIV infection (full text here). In hospital epidemiology we're very familiar with post-exposure prophylaxis (PEP) for healthcare workers who sustain percutaneous exposures or blood/body fluid exposures to mucous membranes. This paper evaluated pre-exposure prophylaxis (PrEP) for men who have sex with men by having the study subjects take a daily dose of truvada. New HIV infections were compared in the treatment group to men who were assigned to take a placebo daily. There were roughly 1200 men in each study arm. On average the men were in their late 20s, had more than 1 sex partner weekly, about 60% reported unprotected anal intercourse, and they were followed for roughly 1 year. There were 36 new HIV infections in the Truvada group (2.9%) and 64 new infections in the placebo group (5.3%). This represents a 44% relative risk reduction. Sounds pretty good, but that translates to only a 2.4% absolute risk reduction (the infection rate in the treated group subtracted from the infection rate in the placebo group). When the subset of men with detectable drugs levels (i.e., those who were compliant with Truvada) were compared to those without detectable drug levels, the relative risk reduction was 92%. "That's huge," exclaimed Dr. Anthony Fauci, the head of the National Institutes of Allergy and Infectious Diseases, in the New York Times.

So here we have an intervention that appears to be efficacious but not effective (that is, it works when you take the drug, but in the real world many people just won't take it--we've talked about this before). By my calculations, compliance appeared to be about 38% in the study. However, I think we can be sure that compliance would have been even less in the real world if the study subjects had to pay for the Truvada at the retail price of $13,000 yearly. We're also not told whether those who took the drug faithfully may have also been highly compliant with condom use, which may make the drug appear to be more effective than it actually is. So, in the end, I don't think that the impact of this study will be huge. In fact, I doubt it will have much impact at all. The real issue, it seems to me, is helping people to reduce risk the old fashioned way (fewer sexual partners and consistent use of condoms), until the day finally arrives when we have an effective vaccine for HIV.

Switching gears, as a hospital epidemiologist, I wondered if there is a role for PrEP in the hospital. Let's consider the case of a an untreated HIV infected patient with a high viral load who needs cardiac or orthopedic surgery soon. Should the operative team be given PrEP or perhaps peri-exposure prophylaxis (PeEP), with dosing the day before, the day of the procedure, and the day after? If I were the surgeon, I would be interested in that.

Friday, November 26, 2010

Why we can't work at work

In my previous post, I mentioned what I was going to read during my quiet time this weekend.  We all have to work like this now, since it has become increasingly difficult for us to get work done at work. Our homes are now our offices. What we need is no-talk Thursdays or something like that. This Jason Fried TED video explains:

link for non-flash devices (iPhone etc)

Tuesday, November 23, 2010

Thanksgiving Reading List

I just ripped out a few articles to read over the upcoming holiday.  I may have more things to say on these subjects in the future; however, I didn't want you to lack good reading material for the long weekend.

1) Hospital-acquired C. difficile is associated with 3-fold risk of death which diminishes as baseline severity increases. (source: Oake N et al, Archive Intern Med. Nov 8, 2010)

2) The 7th Edition Mandell, Douglas and Bennet's Principles and Practive of Infectious Diseases is bigger and better than ever- Book Review by Preeti Malani. (source: Malani P JAMA Nov 10, 2010) the book is only 4328 pages, so you can have until Dec 31 to read this one. (Note: I did not specify a specific year)

3) Intentional infection with STDs (GC, chlamydia and syphilis) in vulnerable populations. A new unethical study from 1946-48 has been recently uncovered by Susan Reverby. The CDC Director Dr. Thomas Frieden and NIH Director Dr. Francis Collins report on her findings in JAMA, Nov 20, 2010). A copy of Dr. Reverby's forthcoming article is available on her Wellsley College webpage.  I read her amazing history of nursing in America, Ordered to Care: The Dilemma of American Nursing (New York: Cambridge University Press, 1987) when I was an undergrad at the University of Michigan.  I highly recommend this book as it explores the dilemma of a nursing profession that must care for people in a society that 'doesn't value caring.'  There are general lessons there for public health in the US since it remains unclear how the country values public health resources.

4) Potential opportunities to steamline IRB approval. Millum and Menikoff in Nov 16, 2010 Annals of Internal Medicine offer several under-utilized options for improving the efficiency of ethical review.

5) Significant direct (recipient) and indirect (herd immunity) protection secondary to LAIV vaccination of 4-11 year olds was evident even when there was a mismatch between the vaccine and epidemic strains.  (Source: Glezen WP et al JID Dec 1 2010 and Editorial by EB Lewin - both are free full text)

Happy Thanksgiving, safe travels and may your God go with you.

Monday, November 22, 2010

E. coli 0157:H7 and hypertension, renal and cardiac disease

Text-size doesn't correlate with population size
Another not exactly HAI prevention post, but as Mike just told us, we don't have much evidence in ID, so anything can be exciting, no?  This report out of BMJ tells of a May 2000 E. coli O157:H7 and Campylobacter outbreak that arose in the Walkerton, Ontario municipal water system after heavy rainfall drove livestock faecal matter into water supply. The outbreak resulted in 2300 cases of GI illness, at least 27 cases of haemolytic-uraemic syndrome, and seven deaths.  Amazingly, the government created a Walkerton Health Study to monitor individuals for the possible long-term consequences associated with the infection.  After 4-years, there was a 28% increase in hypertension associated with the exposure.  The BMJ report tells of the impact out to 2008.

Overall, people who had acute gastroenteritis were 1.3 times more likely to develop hypertension, 3.4 times more likely to develop both structural and functional renal impairment, and 2.1 times more likely to report a physician-diagnosed cardiac disease. The authors do an excellent job discussing the potential limitations of the study including recall bias and confounding. They also explain away the impact of Campylobacter coinfection by saying that the infectious dose of 0157:H7 is 10 bacteria, while it is 500 for Campylobacter, so people were unlikely to have avoided 0157:H7 exposure.

This is a very unique study.  Most studies that have assessed infections as risk factors for chronic diseases were case-control studies that identified patients with specific outcomes and looked back for certain risk factors.  You would imagine that recall bias would play a much larger role in remembering certain distant and unremarkable exposures like GI illness in a case-control study. With this cohort study, exposures and outcomes were well characterized and measured.  I wonder what this study's impact will be in ascertaining the causes of hypertension, renal and cardiac disease in the general population?  Their recommendation that patients who are post-exposure from E coli 0157:H7 should be carefully monitored for hypertension and renal disease seems prudent.

Clark WF et al. BMJ Nov. 17, 2010 (open access)

Sunday, November 21, 2010

Occupational transmission of meningococcal disease

This week's MMWR has a report on transmission of meningococcal disease from an infected patient to a police officer who responded to the patient's home and a respiratory therapist who cared for the patient in the Emergency Department. Neither of the secondary cases were offered postexposure prophylaxis. CDC recommends prophylaxis for HCWs with direct exposure to the patient's oral secretions (e.g., performacne of endotracheal intubation). In this case the police officer was not evaluated for prophylaxis because of a delay in contact tracing. However, the MMWR report admits that if the CDC recommendations were followed the police officer may have not been offerred prophylaxis. What's surprising is that CDC didn't revise the recommendation. Given the severity of meningococcal disease I think we need to be more flexible than CDC's recommendation. We offer prophylaxis to any unprotected HCW within 3 feet of the patient.

Listeria: Safety-based date labels, cheese and the FDA

As I've written before, I spent several years on the USDA's National Advisory Committee on Microbiological Criteria For Foods (NACMCF).  We spent several years writing scientific briefs on a variety of topics. During 2002-2004, I worked on a subcommittee looking at "Criteria for Refrigerated Shelf-life Based on Safety."  For someone who didn't spend 100% of my time on food-safety issues, I was initially surprised that the dates on foods were not at all related to safety.  Dates on that yogurt you are about to eat are based on palatability, FYI.

The document we produced and then published in 2005 in the Journal of Food Protection was predominately a Listeria control document even though we considered four psychrotrophic pathogens: L. monocytogenes, nonproteolytic C. botulinum, Y. enterocolitica, and B. cereus. The hope was that a safety-date on refrigerated foods, when combined with education about proper storage and handling of these foods, could reduce the health risk in the very young, very old, immunocompromised and pregnant women, who are at increased risk for miscarriages and stillbirths after Listeria infection.  Of course, any safety-based date label would have little impact if the food is highly contaminated during production. 

One thing I noticed serving on NACMCF was the hard work and honest efforts of the others on the committee. Even though some members worked for industry, some worked for the government and some had worked for both, they all tried hard to produce a good document. There was no evidence of some conspiracy to harm the public.  Outbreaks of foodborne illness are bad for everybody. Producers looked to government to set standards and then helped determine the best ways to meet those standards.

With that background, I was shocked to read recently in the NY Times about an artisanal cheese producer from Washington state who was defying a recall order from the FDA. Her cheeses were found to be contaminated with Listeria.  She and others are claiming that the FDA is going after the little producers - a David vs Goliath story.  Senators and others are rallying to modify the food safety bill in the Senate that I blogged about last week, in an effort to exempt these types of small producers.  They suggest that the real risk is in the big producers since they make the most foods, but I think they are making a very poor decision.  If you had the choice to buy cheese that was subject to regulation and unlikely to be contaminated or some cheese that wasn't tested for safety, which would you buy?  I agree with William Marler, a Seattle food safety lawyer, who said he just doesn't "know how they make the leap from the government trying to do the right thing for public health to ‘they’re food Nazis in the pocket of big agribusiness.’ ”

What if we had that situation in HAI prevention? What if big hospitals had to publicly report CLABSIs and follow Joint Commission standards and small hospitals got a free pass? Wouldn't that be the quickest path for bankruptcy for small hospitals? It would be hard to imagine small hospitals claiming that they only take care of a few patients so a few excess deaths don't matter, but that is exactly what the small food producers are claiming in the NY Times article.

Falsum in uno, falsum in omnibus
It seems that we currently live under a logical fallacy, where the government is evil and people claim that the government is bad at everything. Sure, government has its faults and could improve its efficiency, but when we get to a point where we are saying that small food producers shouldn't have to be regulated and thus produce safe food, we have gone too far. I would love to support local producers and serve fresh produce in my home, but I won't do it if they get a free pass on safety.  I hope they can work out a compromise where the FDA and small producers can work together.

NY Times article: Small Cheesemaker Defies F.D.A. Over Recall - November 19, 2010

Saturday, November 20, 2010

The specialty of Infectious Diseases: More art than science?

The November 15 issue of Clinical Infectious Diseases has an interesting paper that evaluates the quality of the IDSA clinical practice guielines. The authors reviewed 44 current guidelines available at the time of the study, which consisted of 4,182 component recommendations. Over half (55%) of the recommendations were based on level III evidence (expert opinion or descriptive studies), and only 15% were based on level I evidence (at least 1 randomized controlled trial). Of note, when revised guidelines were compared to their corresponding original versions, there was a 12% relative increase in recommendations backed by level I evidence, though that was only a 1.6% absolute increase. Just goes to show you that infectious diseases is still in its infancy as a specialty and the unknown remains vast. This must be why I often feel like I am flying by the seat of my pants

Friday, November 19, 2010

CDC's Get Smart for Healthcare program

Arjun Srinivasan, Medical Director for CDC’s “Get Smart for Healthcare” campaign, and Ramanan Laxminarayan, Director of Extending the Cure, co-authored a recent piece in the Health Care Blog. It describes the current crisis with carbepenem-resistant Enterobacteriaceae and how the CDC and partners are responding. For example, this week, they launched the “Get Smart for Healthcare” program which complements the existing “Get Smart: Know When Antibiotics Work” program. I will let you read what Arjun and Ramaman have to say...

link: The Health Care Blog

h/t: Mark Vander Weg

Thursday, November 18, 2010

Accentuate the positive, eliminate the negative….

It sounds like a good idea when Mr. Bing Crosby croons it, but it’s not good for science. Negative studies are every bit as important as positive ones, but they are much less likely to be published. There are many reasons for this, but one of them (positive outcome bias by manuscript reviewers) is carefully examined in an interesting study found in the November 22 issue of the Archives of Internal Medicine (Emerson GB, et al. Arch Intern Med 2010;170:1934).

The investigators fabricated two versions of a manuscript (a “positive” version and a “no-difference” version), purposefully placing minor errors in each. They randomly sent one version or the other to over 200 peer reviewers. Their findings? Not only was the positive version more likely to be recommended for publication, but reviewers were less likely to detect the errors in the positive version, and more likely to score the methods section of the positive version higher (despite the fact that the methods sections were identical).

So listen up, authors, reviewers and journal editors: stop accentuating the positive and eliminating the negative! Submit those high-quality negative studies, review them fairly, and get them out there for all to see.

One thing Bing Crosby and I can agree on, though...you still shouldn’t mess with Mr. In-Between.

Food Safety Modernization Act

Senator Durbin (D IL)

Not hospital infection prevention, but still infection prevention.  I won't go into too much detail, but the Senate may "pass" the FSMA - S. 510 tonight - this would change how the FDA regulates what it regulates, which is to say, not all foods.  You can read Michael Pollen's take on the bill here.  From what I gather, this won't impact USDA, CDC, and NOAA's NMFS etc.  Will be interesting to see what happens and also how the 'spinmeisters' treat this.  There has been surprisingly little mentioned about this given how important food safety is.

Wednesday, November 17, 2010

DHHS releases 2010 Adverse Events in Hospitals report

The Department of Health and Human services just released an 81-page report titled: Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries. Using a nationally representative random sample of 780 Medicare beneficiaries discharged in October 2008, physicians determined (1) whether an adverse event occurred, (2) whether the event was an NQF Serious Reportable Event or a Medicare hospital-acquired conditions, (3) what the level of harm was to the patient, and (4) whether the event was preventable.  Using this sample, they estimated that 13.5% of all hospitalized Medicare patients experienced an adverse event and in 1.5% the AE contributed to their deaths.  These extrapolate to 134,000 adverse events and 15,000 deaths in a single month. Multiply by 11.7498 (or 365.2425/31) if you want yearly estimates for an average year.  Yes, I'm being a smart a**, but multiplying by 12 is incorrect.

One thing we're always concerned about on this blog is the percent of HAIs that are actually preventable in the current 'get to zero' world that we live in.  In the DHHS report, physicians estimated that 44% of the AEs were preventable, 51% were not preventable and in 5% they were unsure.  The costs were $324 million in October 2008 or 3.5% of all hospitalization costs. They suggest that the FY2009 attributable costs of AEs were $4.4 billion, with two-thirds of the costs being associated with extended hospital stays.

So what about HAIs?  Table 3 in the report classifies the 128 AEs into categories and 19 or 15% of the AEs were HAIs.  Thus, 2.5% of all hospitalized Medicare patients had an HAI. There were 5 UTIs, 4 CLABSI, 4 other BSI, 4 RTIs and 2 SSIs.  The physicians classified only 60% of the infections as preventable.  I wonder if this will help Mike achieve one of his wishes for the 2010 New Year? I could probably dig deeper but I've got work to do and I don't want to ruin all of your fun.

Link: November 2010 DHHS Adverse Events in Hospitals report.

h/t: Megan McKenna

Tuesday, November 16, 2010


I had a wonderful week helping deliver medical supplies to hospitals in Camaguey, Cuba. I met so many dedicated healthcare professionals, well-trained and working hard for an average monthly salary that approximates $25 US dollars. One of Cuba’s main industries is training and exporting physicians, it has a higher physician-patient ratio and lower child mortality than the United States, a life expectancy of 77 years, and an intact public health and primary care system that emphasizes prevention. However, many of the acute care hospitals we visited were in poor repair and were frustratingly low on essential supplies and simple technology.

But rather than go on about the Cuban healthcare system as if I know what I’m talking about after one short week, I’ll link to an excellent recent article by Laurie Garrett. We were not in Havana to see the Clínica Central Cira García that she describes, but the rest of what she writes is in line with my observations and with what I heard from the physicians I spoke with there.

Castrocare in Crisis, by Laurie Garrett

Maryn McKenna visits Iowa City (and 1957 Cleveland)

McKenna's latest book
We've written before about Maryn McKenna, who is the author of Superbug, a journalist and a blogger.  After PepsiGate tore through ScienceBlogs, she had to relocate her blog to here and finally here, so I wanted to make sure you all could still find her.  She writes extensively about antibiotic resistance and other infectious diseases at Wired - she knows her science, which is rare among journalists, and she's a wonderful storyteller too.  Check out her latest post on the pre-publication NDM-1 EID papers.

Maryn was on the UI campus today and spoke at a UI College of Public Health conference on MRSA; she gave a wonderful history of resistant Staphylococcus aureus and MRSA. She even mentioned in passing the important conference in Cleveland on November 14, 1957.

Do you know that conference?  This conference was sponsored by 15 organizations including the AMA with ACP, ACS, AHA, ACOG, AAP, VA, CDC, USPHS, FDA and APHA among others. The presentations and discussions at this conference led to the development of a national program for the eradication of S. aureus in hospitals and to the following recommendations for the AMA trustees:

1. That every hospital establish a responsible officer or committee charged with the investigation and control of infections within that hospital and with the institution of procedures and practices designed to prevent such infections.

2. That encouragement and funds be channeled into scientific research concerning the etiology and epidemiology and the immune relationships of pyogenic staphylococci, their relationships to the defensive cells of the body and the mechanism of their mutability to drug and antibiotic resistance.

The AMA trustees approved this within one month and referred it to the Joint Commission, which in the spring of 1958 added #1 above to the requirements for hospitals seeking accreditation. Thus we have these people, groups and S. aureus to thank for infection control programs as we know them today. I wonder if we need a similar conference now on MDR-Gram negatives?

Question: Why was the conference in Cleveland?

Perhaps because Charles Henry Rammelkamp, Jr., M.D was there. He was well known for his work demonstrating the impact of a sulfonamide derivatives on staphylococci and reporting the first penicillin-resistant strain of staphylococcus. He also contributed to the understanding of the epidemiology of staphylococci in nurseries and the role of coagulase in the evolution of staphylococcal disease.  Not sure if that's why, but seems like a good enough reason to me.

Monday, November 15, 2010

Compehensive Infection Control Campaign (video)

"The Blues ain't about making yourself feel better, it's about making other people feel worse." - Bleeding Gums Murphy to Lisa Simpson

I was, as we used to say, 'surfing the web' looking for implementation ideas for infection control interventions, particularly hand hygiene, when I stumbled on this video.  I really like this campaign from University College London Hospitals and especially liked the lenticular buttons and posters. "Give Bugs Hell. Use the Gel" and "1 in 3 of us carry bacteria that can kill" were effective I think, as was the Blues.

I found it interesting that Chairman, Sir Peter Dixon was worried that "there was a risk to doing this" campaign since it might suggest they have an active problem with HAIs at the UCLH rather than the truth that they were "launching this because they wanted to stay on top of this."  That sums up infection prevention and public health in a nutshell I think.  I'm impressed with his comments and UCLH's campaign.

Friday, November 12, 2010

Another reason to wear a wide-brimmed hat to the beach

Attacking seagulls Dewey Beach, Delaware 2007
These days, with everyone worried about skin cancer, one shouldn't go to the beach without plenty of sun screen and one of those wide-brimmed floppy hats that protects your cabeza. Now you have another reason to look totally awesome at the beach - VRE protection.  That's right.  Researchers collected 57 faecal samples of Seagulls (Larus cachinnans) of Berlengas Natural Reserve in Portugal.  Using a combined proteomic and genomic approach they found that 95% of the gulls had detectable Enterococcus isolates with 50% being E. faecium and 10% E. faecalis with the remainder being other species. Around 10% had vanA containing VRE (Four E. faecium and two E. durans). Other resistance genes were detected including tet(M) and erm(B).

Of course finding VRE in other species isn't the true discovery here as the authors state they've identified proteins involved in both antibiotic resistance and the stress response in vanA-containing enterococci. They also suggest that their results may reflect the expression of a few membrane proteins involved in resistance which could be targets for the development of novel antibiotics.  I can't comment much on that, but I am going to wear my large-brimmed hat to the beach.

Radhouani et al. Proteome Science 2010.

Thursday, November 11, 2010

Post #610: Happy "Get Smart About Antibiotics Week" (November 15-21, 2010)

Man, have we done a lot of posting in the past 1.5 years.  I think Dan and Mike will agree with me here when I say that none of our posts have been as important as this one.  None.  The reason for this is that I'm announcing a whole 7 days of celebrating and not just one day. The world has witnessed Global Handwashing DayWorld Hand Hygiene Day, and World MRSA Day this past year.

But notice, these were just on single days.  Thus, we can officially announce that the smart use of antibiotics is 7 times more important than MRSA and 7/2 or 3.5 times more important than the domain of handwashing/hand hygiene. These are two questions that as an epidemiologist I've been struggling to answer for 10+ years and now I finally know.  While it is true that this is the 3rd annual "Get Smart About Antibiotics Week" and I should have officially known this two years ago, I do like to wait for "replication of results" or reproducibility before drawing a firm conclusion on such important questions. Alright everybody, get ready and Get Smart about antibiotics!

Special Invited Veterans Day Post on MRSA

For the Veterans Day post, it is worthwhile mentioning the role of the VA in advancing research on infection prevention. Despite some bureaucratic hurdles, the VA has supported some of the more creative work over the years and having one of the few fully electronic medical record systems, has the potential to implement a more sophisticated approach to infection prevention.

A recent, high profile intervention in the VA is the MRSA Prevention Initiative. Mobilizing millions of dollars with a top down mandate, the VA has focused efforts on infection control, especially as it relates to MRSA. The majority of the intervention relates to improved hand hygiene and compliance with Standard and Contact Precautions and encourages involvement of local healthcare workers through positive deviance. More controversial was the mandate to perform active surveillance for MRSA, swabbing patients admitted to acute-care facilities almost ceaselessly (admission, transfer and discharge, obtaining > 90% compliance in many facilities). While no verdict has been reached on the effectiveness of active surveillance for MRSA, the VA, to its credit, has supported research into alternative approaches.

One of these alternative approaches was hatched by a mentor of mine known to this blog simply as Eli. Focusing on the known risk factors for MRSA as a means of identifying patients at high risk for carriage, he and I looked at simple rules that could predict patients who should be targeted for MRSA (and VRE) screening. In a closed system like the VA with a fully electronic medical record, these prediction rules could be automated. In the Baltimore VA, we examined possible prediction rules and found that documentation of antibiotic use within the past year identified 84% of the risk of MRSA transmission and 98% of the risk of VRE transmission. In other words, if the electronic medical record had documentation of antibiotic use, an order could have been automatically generated at time of admission for MRSA or VRE culturing. This testing would identify virtually all patients with VRE and most with MRSA while culturing half the patients currently subjected to swabbing. The full effect of such an approach needs investigation in other VA populations but is promising.

At a time when attention is turning towards generating solid data on sometimes intrusive infection control interventions, I’d like to salute the VA for taking the lead on supporting research that may help transform hospital epidemiology from expert opinion to a scientifically outcomes based field.

Note: Special thanks to our guest blogger and author of the discussed ICHE paper, Dan Morgan. Dan is an assistant professor at the University of Maryland and currently supported by an AHRQ K-award to study the non-infectious consequences of contact isolation.

Wednesday, November 10, 2010

The dumb list just got longer

Over the past year, I've been keeping a list of really dumb things hospitals have done to reduce infections. Here's the latest:
  • A Toronto hospital is banning magazines in waiting rooms. While they're at it, I think they should also ban chairs--there are bacteria on chairs, you know?
Other banned items and activities from our archives:

Public Reporting of CLABSI: Is it a valid measure for hospital comparison?

Overview of the computerized CLABSI agorithm
In today's JAMA, Michael Lin and authors from four CDC Epicenter academic hospitals (2 in Chicago, 1 in Columbus, OH and 1 in St. Louis) compared annual IP-determined CLABSI rates in 20 ICUs during 2004-2007 with a computer-generated reference standard. The median CLABSI rate was 3.3/1000 central line days. Overall correlation with the computer algorithm was poor at 0.34 and ranged from 0.83 in one center down to 0.10 at another. Interestingly, the center with the lowest reported CLABSI rate by IP had the highest computer rate. (2.4/1000 CL-days vs. 12.6/1000 CL-days)

I have posted the schematic of the computer algorithm and also the link to the code (below).  My only methods question (at this moment) is why did they limited the analysis to yearly comparisons and not quarterly or monthly comparisons.  I would have liked to see that level of data analyzed even though it would be noisier.  It was interesting how the IP-reported rates were narrowly clustered around each other while the computer-generated rates were widely distributed.  The findings should make us pause when we consider public reporting of these rates.  If so much emphasis is being placed on CLABSI rates at the state and national level for comparison and reimbursement, there should be funded validation of the reported rates and also consideration of other measures (outcome or process) that might be more reliable. 

Lin et al JAMA November 2010
Link to computer algorithm code (looks like you might need to apply for a password)

Tuesday, November 9, 2010

Oseltamivir+Zanamivir combination therapy vs monotherapy for seasonal influenza

A Combination Lock
In infectious diseases, there is always the trade-off between treating the individual patient and the population effects of antimicrobial resistance.  One way to counteract the development of resistance might be combination therapy (eg HIV ART) but this would only apply if the combination provided an added benefit to the individual patient with minimal side effects.  To answer this question for influenza, researchers in France in fall 2009 (85% H3N2 virus) conducted an RCT comparing oral oseltamivir 75 mg twice daily plus zanamivir 10 mg by inhalation twice daily to oral oseltamivir monotherapy or inhaled zanamivir monotherapy. The primary outcome was the proportion of patients with nasal influenza reverse transcription (RT)-PCR below 200 copies genome equivalent (cgeq)/µl at day 2. They also tracked symptom resolution out to day 14 among other outcomes.

The researchers planned to enroll 900 patients with ILI<36 hours and a positive rapid influenza A test, however the RCT was halted after only 541 (447 with confirmed virus) were enrolled.  In the intention to treat analysis, 46% in the O+Z group reached RCT-PCR<200, while this was achieved in 59% of the oseltamivir monotherapy and 34% of the zanamivir monotherapy groups.  Nausea and/or vomiting was more frequent in the combination arm.  Thus, the trial was ended early. The authors concluded: "Despite the theoretical potential for the reduction of the emergence of antiviral resistance, the lower effectiveness of this combination calls for caution in its use in clinical practice."

Duval et al. PLoS Medicine November 2, 2010

Monday, November 8, 2010

1st Annual Illinois Conference on HAI: The SSI rates don't exist anymore edition

I ate all of the Illinois-shaped
chocolates. Sorry!
I had the pleasure of attending and speaking at the Illinois APIC conference this past Friday in Springfield, Illinois.  Lincoln was everywhere for some reason; I was expecting Homer or Bart statues...

The first speaker was Kathy Allen-Bridson, RN BSN CIC who is a Nurse Consultant at CDC's NHSN.  She gave an excellent talk describing how to apply NHSN definitions. She, Marc Wright (one of the conference organizers), Joan Hebden, Gloria Morrell and Teresa Horan have published a series of cases studies that aid IPs in the application of NHSN definitions of HAIs.  The first three of these have appeared in the June, September and October issues of APIC. (scroll down to the Special Article section)  I do think that these should be free to everyone and not require a membership or subscription, especially given the large role that CDC had in creating these vignettes.

As far as CLABSI definitions, there was some interesting discussion around Criterion 2 that requires the "same" skin contaminant from >2 blood cultures drawn <2 days apart. For the definition of same, NHSN suggests
that organisms are the same if they have the same antimicrobial sensitivities or only differ in susceptibility to ONE antibiotic.  Thus if they differ by 2 or more antibiotic susceptibilities then they are different and the BSI is not a CLABSI.  The interesting discussion came up around what to do with susceptibilities tested by the microbiology lab, but not reported.  Since some/many labs only report susceptibilities to clinicians for antibiotics on formulary or unrestricted antibiotics, should IPs go to the lab and search for susceptibility mismatch on antibiotics tested in the lab but not reported?  A show of hands suggested that 50% do the extra search and 50% don't.  This is something NHSN might want to address.

Happy Monday: Two Monitors

These strips will have relevance to my old HCOR friends

Saturday, November 6, 2010

A really easy way to reduce blood culture contamination

A new paper in the Journal of Clinical Microbiology caught my eye. By making a minor modification in blood culture collection technique, the study's authors demonstrated a reduction in blood culture contamination by 50% (2.8% vs. 1.4%, p=0.005). Using a butterfly needle and a vacutainer system, an extra tube was used to collect the first mL of blood. This tube was discarded, then the blood was obtained for the culture. The authors hypothesized that skin fragments contaminated with bacteria from the venipuncture can lead to contamination of the blood culture. By discarding the initial 1 mL containing the skin fragments, a significant reduction in blood culture contamination was noted.

Photo of the day

For the politically active epidemiologist, a photo from the Jon Stewart Rally to Restore Sanity:
From:  Sociological Images

Headline: "Hospital Accused of Putting Patients at Risk to Cut Costs"

The Milwaukee News reports that 5 patients at a local hospital are suing the hospital after acquiring infections following surgery. Lawsuits involving nosocomial infections aren't unique, but the argument at play in these cases appears to be, and should be of great interest to hospital administrators and the infection prevention community. The plaintiffs claim that the hospital cut positions in its infection control unit as part of a cost savings plan while building a $400 million new facility. This begs the question: what is the appropriate level of resources hospitals should provide for infection prevention? There is no current national standard to answer this question. But I wonder if the public would be better served if legislative activity focusing on HAIs mandated resources (e.g., IPs/100 beds) rather than particular strategies, such as active surveillance for MRSA.

Needed: Some new antibiotics

The New York Times, 11/6/10
This morning's New York Times has an article by Andrew Pollack on the problem of the pharmaceutical industry's lack of interest in developing new antibiotics. From an economic perspective, it's hard to entice companies to develop drugs that a patient might need for a few weeks, when other drugs may be required for years. Yet the problem of multidrug-resistance, particularly for gram-negative organisms, continues to accelerate. Pollack points out the lack of consumer advocacy on this issue, noting that advocacy has focused on reducing transmission of infections in hospitals, rather than the development of new therapeutics.

Thursday, November 4, 2010

Off to Cuba

I’ll be leaving the blogging to Eli and Mike for the next 10 days, as I head off to Cuba tomorrow. I’m going with the Wisconsin Medical Project, delivering medical supplies to healthcare facilities in Camaguey. I look forward to learning more about the healthcare system in Cuba. Unfortunately, internet access in Cuba is somewhat limited, so I'll probably not check in again until I'm back.

Wednesday, November 3, 2010

What's in a name? APIC Name Change 2010 Edition

O, be some other name!
What's in a name? that which we call a rose
By any other name would smell as sweet;
-Romeo and Juliet

This just in (to me at least)...for the second year running APIC members have cast ballots in favor of changing their name to "Association for the Prevention of Infections”, replacing the original “Association for Professionals in Infection Control and Epidemiology" yet they did not achieve the necessary two-thirds majority to change the name.  Thus, APIC will have the same meaning at least for another year. For some reason, I've always thought APIC stood for "Spreading knowledge Preventing infection TM," so I'm a bit relieved that it doesn't.

Despite being an APIC member, I don't have a strong opinion on the name change. However, I wonder what the reasons are behind the failure to obtain the necessary super majority?  Perhaps dropping the word "Professional" might upset members since it could suggest a movement away from career development activities towards a purely outcomes-based organization.  For me, I like that "Epidemiology" is in the current name even if it's not in the acronym - I guess it is an invisible "E" instead of the usual silent "e"

Deciding what to name your organization or meeting can be quite tricky. I've been recently involved in a similar process within our research group at the Iowa City VA and have found it interesting to see how some people really favor one name, others strongly favor a different name and all have legitimately good reasons that are hard to reconcile. 

Recently, I heard that there's been a debate as to what the 2012 combined SHEA-IDSA meeting should be called.  Someone told me that they wanted to name it "ID Week" not to be confused with "National Pet ID Week," or "Protect Your ID Week (October 17-23)" or even "ID Weak."  I suspect SHEA members will not like that name as it buries Hospital Epidemiology and not all people involved in SHEA activities see themselves as "Infectious Disease." One nice suggestion I heard was that the meeting name should incorporate SHEA, HIVMA, IDSA and the ASTMH, the tropical medicine society. Somehow that seems about right.

Tuesday, November 2, 2010

Outbreak Investigation: Internet vs Telephone Inteviews?

There is an interesting report out in the November EID by Johns Oh and colleagues in Oregon.  During a 475-mile bike ride in fall 2009, six riders reported a GI illness that was confirmed as norovirus.  To obtain additional information from other riders, Oregon Public Health officials identified the 1,288 riders who were Oregon residents and administered a 95-item survey using one of two methods at random.  204 completed the survey over the internet and 93 over the telephone (it took me a minute to remember what a telephone was...)

The findings were a bit surprising.  While a similar percent initiated the survey, 76% internet vs 84% telephone, only 64% completed the survey on the internet vs 79% who completed it on the phone, p=0.01. Internet responders were much less likely to complete the food item questionnaire (57% vs 94% on the telephone). What was most surprising is that older riders >50yo completed the internet survey much more often compared to those <50yo (70% vs 56%, p=0.05).  I guess the internet is distracting especially to young people. Who won the World Series again and what's the weather like outside? I'm sure older riders were more likely to have window offices and thus didn't need the internet to answer that last question.  One caveat that the authors made is that the findings in this study might not be generalizable to lower socioeconomic groups with low levels of internet access - for example 201 of 204 riders in the internet survey had valid email addresses; this is likely higher than the general population.

Oh JY et al. EID November 2010

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