Friday, December 31, 2010

California's Healthcare Associated Infections Report: For what it's worth...

California has just released its first statewide report on healthcare associated infections (you can view it here). The metrics reported are healthcare associated VRE bloodstream infections per 1,000 inpatient days, healthcare associated MRSA bloodstream infections per 1,000 inpatient days, and CLABSI in ICUs per 1,000 central line days. The report has major problems as evidenced by the disclaimer on every table of rates that says that the data should not be compared between hospitals, which is generally the whole purpose of public reporting. However, since the reporting period for this report ended, the state mandated that all hospitals join NHSN, which they anticipate will improve the quality of the data reported.

Wednesday, December 29, 2010

Whither the physical exam?

JAMA just posted an online piece about the physical examination of obese patients. The gist is that all of our usual examination techniques are “undermined when the viscera and vasculature are enveloped in a thick layer of adipose tissue.” The authors call for improved training on the adaptation of physical examination to the obese patient.

The physician in me agrees that if the physical exam is of any value, we ought to be better trained to perform it on all patients, obese or not. But the hospital epidemiologist in me asks: how useful is the physical examination, and how often should it be performed in the acute care setting?

Consider what we know about the utility of the physical exam, the efficiency of pathogen transmission by direct contact, and the difficulty of achieving sustained excellence in hand hygiene (not to mention the disinfection of stethoscopes, coats, etc.). Is it wise to encourage multiple potential examiners (medical students, interns, residents, attendings, consulting physician teams, nurses, respiratory therapists) to have such frequent direct contact with acutely ill hospitalized patients?

I have alluded to this issue before, but in the spirit of this blog’s title (controversies), I’ll state the question more directly. Is it time to re-evaluate our physical examination practices in the acute care setting?

Monday, December 27, 2010

Don't eat this house!

Today’s holiday advice: avoid houses constructed of cake and frosting. Assuming you manage to avoid being eaten by a witch, you face the threat of staphylococcal food poisoning. The Illinois Department of Public Health reports that several outbreaks of food-borne illness have been linked to an Illinois bakery with the unfortunate name Rolf’s.

Saturday, December 25, 2010

Bair Hugger vs HotDog

This morning's New York Times business section has an article about Dr. Scott Augustine, the inventor of the Bair Hugger, a device used in the operating room that uses forced air to keep patients warm so as to reduce postoperative infections. Perioperative warming is one of the Surgical Care Improvement Project (SCIP) metrics. The Bair Hugger is now made by Arizant and Dr. Augustine no longer has any connection to the product. He has invented a new warming product that uses conductive fabric, called the HotDog warmer, and now claims that the Bair Hugger causes infections. The New York Times article points out that there may be some theoretical concerns for infection caused by the Bair Hugger, but no definitive evidence.

Addendum 12/30/10:
Dr. Scott Augustine emailed me about this posting and included a video which allows you to visualize the air currents when a forced air warming device is used. It's worth viewing and I think demonstrates plausibility for increased infection risk.

Wednesday, December 22, 2010

And one more holiday gift idea...

I was in Whole Foods yesterday and simply could not resist buying this wine for one of my Infectious Disease partners. 

How cool is that? 

And there will be prizes!

The U.S. Department of Health and Human Services just sent me an e-mail announcing two new national awards to recognize success in “reducing and eliminating central-line associated bloodstream infection and ventilator-associated pneumonia.” The awards are co-sponsored by the Critical Care Societies Collaborative.

The announcement states that the awards are intended to motivate. There should already be several potent motivators at work here (e.g. saving lives, reducing lengths of hospital stay and costs, CMS public disclosure requirements, etc.). But if the prospect of getting a plaque and a free trip to Chicago is what your organization needs to get over the hump, then by all means get to work. I’m also in favor of anything that raises the profile of HAI prevention, so it is good to see on that level.

Speaking of raising profiles, there was a very similar award presented at the Fifth Decennial, to recognize excellent team performance in infection prevention. It would have been nice to see SHEA, APIC and IDSA co-sponsoring this, too.

Award announcement here

Tuesday, December 21, 2010

One more time: Wash. Your. Hands.

A new paper in Anesthesia and Analgesia takes a look at hand hygiene by anesthesia providers and transmission of organisms from their hands to anesthesia equipment and patients' IV stopcocks. The study was performed at Dartmouth and Kathy Kirkland was one of the authors. The study looked at 1st and 2nd cases in selected operating rooms. After cleaning, the anesthesia machine was cultured. Then the anesthesia provider's hands were cultured and after the case the anesthesia machine and patient IV stopcocks were cultured. The room was then cleaned, and the same algorithm for cultures was followed for the second case. Bioptyping of isolates was performed to determine whether the organism on the providers' hands matched the environmental isolates.

The major findings were:

  • The hands of the anesthesia provider were contaminated with one or more major pathogens 66% of the time
  • Bacterial transmission to the IV stopcock set occurred in 11.5% of the cases, with 47% of the isolates matching those on the anesthesia provider's hands
  • Bacterial transmission to the anesthesia machine occurred in 89% of the cases, with 12% of the isolates matching those on the anesthesia provider's hands
Over the past several years much attention has been paid to improving compliance with surgical antimicrobial prophylaxis and improving hand hygiene compliance outside the OR. Moreover, surgical hand hygiene has been an integral part of the OR routine for eons. However, little attention has been paid to hand hygiene compliance by anesthesia personnel. Kathy and her colleagues have probably now changed that. Ok Anesthesia people, wash up!  

Monday, December 20, 2010

Having fun with Ngram

One day last week on my way to the gym, I heard this NPR story on Google's Ngram Viewer. This is a tool that anyone can use to search for the usage of words or phases across 4 centuries of books (5 million books containing 500 billion words). According to the NPR piece, Google has digitized 15 million books, which is about 15% of all books ever published.

So I decided to give it a try.  Here I typed in the word "MRSA" and this is what I found:
The axis font is too small to read but the x-axis starts at 1800 and you see the blue line begin to emerge at about 1960. The far right x-axis gridline is the year 2000. There are 40 years between each x-axis gridline.

Next, I searched two separate terms, "influenza" and "MRSA." In this graph, influenza is the red line and MRSA is the blue line. The big red line spike occurs at 1920.

And here, I added "malaria" (shown in green) to the mix:

So looking at the big picture (at least as far back as 1800), gives us some perspective--perhaps more of a public health view.

Can't you tell that I'm now on vacation and have too much time on my hands?

Sunday, December 19, 2010

Sunday Times blogging

This report from Arizona serves as a disturbing reminder of how quickly bad health outcomes data can be turned into bad public policy. And this report from Zimbabwe provides some needed perspective on the enormous healthcare gap between the richest and poorest nations. If we had to steam-clean all disposable gloves for re-use, we'd probably find some alternatives to widespread use of contact precautions!

Wednesday, December 15, 2010

Fecal transplantation for C. difficile

The Washington Post had an article yesterday on fecal transplantation for C. difficile colitis. I've done a number of these procedures, including one last week, and another to be done next week. It's amazingly simple--mix donor stool with water in a blender, pour the suspension through filter paper twice, and then administer 25 mL of the suspension via an NG tube into the recipient. The patient typically experiences relief of symptoms within  24 hours. As pointed out in the article, there have not been any formal trials of this treatment. And as bad as it sounds, the patients I have treated didn't think twice when offered the treatment. Some have even sought out the treatment themselves after mulitple episodes of C. difficile. Here's an interesting paper on performing fecal transplantation at home with directions for do-it-your-selfers.

Only 48 million get food poisoning annually in the US

Good news (not really). Through an estimate derived through 'substantially improved methods', the number of people who are thought to get sick annually via food poisoning fell from 76 million to 48 million.  That's fantastic. Annual deaths fell from 5000 down to 3000.

The two reports on illness due to major recognized pathogens and unspecified agents along with an editorial by one of my Maryland mentors, Glenn Morris, have been published in expedited form in EID.

I hope the timing of the article doesn't impact the bill modernizing the FDA that recently passed  in the Senate but has yet to make it to President Obama. 48 million and 3000 are too many, especially in 2010.

Ominously, Glenn Morris points out in the editorial that "if one looks simply at rates of overall gastrointestinal illness in the United States, based on FoodNet Population Surveys, one might infer that overall rates of acute gastrointestinal illness have increased during this period, from 0.49 episodes per person per year in 2000–2001, to 0.54 in 2002–2003, and to 0.73 in 2006–2007."  On the plus side. Morris suggests that using FoodNet data "the overall trends show an initial drop in incidence of infection with the major bacterial foodborne pathogens after implementation of the 1995 USDA regulations, followed by a leveling off of incidence in subsequent years."

Well, there is some good news.  We now have more accurate estimates of infections due to foodborne pathogens in the US. When you have better data, you can have a a more modern, risk-based food safety system.  This is why Dan and I argued in our recent JAMA editorial that we need a continued expansion of the existing but somewhat limited hospital-infection and MDRO surveillance system in the US.

see also: William Neuman NY Times article

How and why does Staphylococcus aureus target humans?

I wish I could swim like a dolphin
Researchers from Vanderbilt in the December 16 Issue of Cell Host & Microbe have reported the discovery of the mechanism by which S. aureus preferentially binds human hemoglobin in it's search for the iron necessary for proliferation. The authors suggest that perhaps variation in human hemoglobin explains why some people are not likely to be colonized/infected and others are.

The comment made in the NY Times article about being higher up on the evolutionary scale is a risk factor for S. aureus attraction to hemoglobin seems a bit dubious. For example, most of us think dolphins are at the highest level of evolutionary ladder and they weren't studied from what I can tell. ;)

NY Times article

Pishchany G et al. Cell Host & Microbe, December 16, 2010

Tuesday, December 14, 2010

More on the "Truth Wearing Off" and my advice to epidemiologists of all ages

Andrew Gelman, a Professor of Statistics at Columbia, has a new post discussing the New Yorker article I mentioned last week.  I highly recommend that you look at the the article that he wrote in American Scientist discussing the statistical challenges in estimating small effects.

My favorite passage: "Statistical power refers to the probability that a study will find a statistically significant effect if one is actually present. For a given true effect size, studies with larger samples have more power. As we have discussed here, “underpowered” studies are unlikely to reach statistical significance and, perhaps more importantly, they drastically overestimate effect size estimates. Simply put, the noise is stronger than the signal."

Thus, when small 'underpowered' studies actually find an effect, it has to be a very large effect to reach statistical significance. So, small studies report overestimates of the effect.

One thing we know about before-after, quasi-experimental studies, which are commonly used in assessing infection prevention interventions, is that they are underpowered and over-estimate the effect compared to randomized trials.  Power is derived from sample size, effect size AND study design, among other things.

QE studies in our field also suffer from publication bias since many have been completed by clinicians who won't go through the trouble of reporting negative studies.  How many papers have you read in ICHE/AJIC/CID that mentioned ADI for MRSA not working?  Even if ADI for MRSA is the greatest control measure ever, which it might be, given a normal distribution of benefit, you would expect some studies to be negative, would you not?  Where are they?

Even, when negative studies do appear (e.g. Harbarth JAMA 2008 or Charlie Huskins hopefully soon to be published STAR-ICU trial) they are often not believed or even thought to be flawed!  Why? Nothing works 100% of the time and a negative study is NOT an erroneous result. A negative study is certainly not prima facie evidence of a flawed study. You must use all of the data, assess it based on quality and power and look for publication bias. (this is my advice to epidemiologists of all ages)

So, are we over-estimating the benefits of ADI and other interventions used in infection prevention?

Link: Gelman's post

Gelman and Weakliem American Scientist, 2009 (PDF)

Sunday, December 12, 2010

Deadly Medicine

The January issue of Vanity Fair has a very interesting investigative piece entitled Deadly Medicine (free full text here) by Donald Bartlett and James Steele, which explores the globalization of the pharmaceutical industry and the effect that has had on the drug approval process. The majority of data used in the new drug approval process now comes from other countries where regulatory oversight is scant. Moreover, they describe co-opting of the FDA by industry. In some countries, doctors enrolling patients in clinical trials can earn 25-fold more money from enrolling one patient than from their monthly salary. This creates huge conflicts of interest. And then there is the exploitation of patients who may not even understand the trial they have been enrolled in and the risks they are bearing. It's a sobering and scary piece, but well worth reading.

Mandatory reporting of HAIs: A work in progress

The December issue of American Journal of Infection Control, has a paper looking at validation of central line associated bloodstream infection (CLABSI) reporting in Connecticut, where all 30 acute care hospitals are required to report CLABSIs from 1 ICU via the National Healthcare Safety Network (NHSN). All positive blood cultures for the fourth quarter of 2008 for these ICUs were reviewed by a trained nurse microbiologist (the gold standard for the study) and compared to locally collected data. A total of 770 blood cultures were reviewed and the validator detected 48 CLABSI cases.

The validity parameters were as follows:

  • Sensitivity  48%
  • Specificity  99%
  • Positive predictive value 85%
  • Negative predictive value  94%
So, as you might suspect even before seeing these data, the major problem with mandatory reporting programs is a failure to adequately detect cases. Keep that in mind when you read through Consumer Reports honor roll of US hospitals that reported no CLABSIs! While I continue to believe that mandatory reporting is the right thing to do, much work is still needed to produce valid data.

Saturday, December 11, 2010

And here's a gift to think twice about before buying...

It's looks like toothbrush sanitizers are the rage this year, with several different products available. After practicing the specialty of infectious diseases for two decades, I must disclose that I've never seen a patient infected by their toothbrush. As long as they are not shared, the germs on the toothbrush are your own, and if that bug caused an infection in you, you're likely to be immune for the short duration it will survive on your tooth brush. But if you can't resist, I'd go with the Zapi, since the design is cool. And it's recommended by Oprah!

Looking for that perfect gift?

Photo: Heifer International
As the holidays approach, here's a cool posting at NPR:  5 Public Health Gifts for the Person Who Has Everything.

More good reading for a winter weekend

The December edition of the Atlantic has 3 interesting pieces if you have any time left over after finishing Eli's weekend reading assignment.

  • Carl Elliott has written a piece on ghostwriting in medical journals (free full text here). He notes that one large pharmaceutical company labelled it's ghostwriting campaign "Case Study Publication for Peer Review." Sounds like a boring campaign name until you look at the acronym (CASPPER). Not so friendly, this ghost, however.
  • Megan Mcardle writes about information technology in medicine (or the lack thereof) in "Paging Dr. Luddite" (free full text here).
  • An eye-opener by Robin Fields, "God Help You. You're on Dialysis," uncovers problems with quality and safety in outpatient dialysis centers and how little is being done about it (free full text here).

Friday, December 10, 2010

Weekend Links or WeekeLinks?

Jackie Robinson Rotunda - Citi Field
Pretty busy around here.  I just gave a talk on seasonal variation in hospital pathogens at the ID research conference this morning.  I saw Dan there.  He is alive, but on service. I think he had 12 consults one afternoon.

We're moving to a new research building next week here at the Iowa City VA, so I'm busy packing up the stuff that I unpacked only 5 months ago when I arrived.  The building is called "Building 42."   42 is Jackie Robinson's uniform number.  Those of you that have seen my old office will remember the Jackie Robinson poster that I had hanging next to the Jim Henson-Kermit poster.  I think I will call the building the 'Robinson Building' or maybe just 'Jackie'.

Here are some interesting posts for your weekend reading pleasure:

4) Clinical outcomes in HAIs and antibiotic resistance in European ICUs (Lancet ID)

Thursday, December 9, 2010

WHO backs rapid test for TB - If only we had rapid treatment

I heard on NPR this morning that the WHO (Keith Moon died 32 years ago) is supporting the new rapid TB test made by Cepheid (MTB/RIF test).  You can read more about the test characteristics in the recent NEJM article. They reported 98% sensitivity in smear-positive patients but only 73% sensitivity in smear-negative patients after a single test.  Sensitivity rises to 85% after a second test and to 90% after a third test.  The test was very good at identifying rifampin-resistant and rifampin-sensitive strains (both around 98% of the time).

The NPR article states that the processor costs $64,000 in US but could be $17,000 for developing countries.  Tests will cost $17.  If you need to do three tests in smear-negative patients to rule out TB with a sensitivity of 90%, it would cost $51. I wonder if developing country budgets can absorb that cost?

Wednesday, December 8, 2010

Communicating Risks

Mike has written several posts on risk perception. What does it mean when we say that a patient has a 3% chance of having an MRSA infection?  How do you communicate that risk to patients or other HCW or even hospital administration?  One aspect of decision science deals with communicating risk; there were several sessions on the topic when I last attended the annual SMDM meeting.

There is a recent post that covers the topic well in Decision Science News, edited by Dan Goldstein from Yahoo! Research and the London Business School. Try to answer the question below.  The answer is available if you expand the post (and if you read the DSN post)

The probability of colorectal cancer in a certain population is 0.3% [base rate]. If a person has colorectal cancer, the probability that the haemoccult test is positive is 50% [sensitivity]. If a person does not have colorectal cancer, the probability that he still tests positive is 3% [false-positive rate]. What is the probability that a person from the population who tests positive actually has colorectal cancer?

Tuesday, December 7, 2010

Where did all of the significant findings go?

There is a really interesting piece in the New Yorker (Dec 13, 2010).  Worth tracking down a copy at your neighbors or dentist's office since the free online version is limited to the abstract.  Jonah Lerher describes in The Truth Wears Off, that initial studies often report large benefits from treatments or large associations between a disease and a specific risk factor which then can't be validated in future studies. 

There are many potential reasons for this 'decline effect' including publication bias - only publishing positive findings, especially in major or high-impact journals.  Dan had a nice post discussing positive outcome bias a couple weeks ago. Another issue might be selective reporting of results by investigators desperate to find strong associations so that they can get published and then get re-funded.  Certainly regression to the mean is important - ye olde bell-shaped curve.  One thing they don't mention is confirmation bias, which I think drives both NIH funding and publication decisions and could be responsible for some of the reduced effect sizes seen in later vs. earlier publications.

This 'decline effect' is troubling given what it says about the scientific process.  One wonders if changes in how science is funded and reported could impact this?

Influenza not taking year off, again! - 3 flu strains in Iowa

Iowa is below Minnesota, to the left of Illinois with a large nose
and small mouth; most consider it the most handsome state.
I thought after last year, influenza would finally take a year off and not cause any problems.  It seems that influenza's streak is getting into Cal Ripken territory.

I also thought that moving to Iowa would limit my exposure to these sorts of transmissible pathogens.  It's not like I see people most days; ain't nobody here but us chickens.  I even thought Dan was joking about measles and mumps.  We have vaccines, we can't possibly have measles and mumps around here!  Apart from what people say, I really do think wishful thinking can prevent influenza if we wish REALLY really hard. If even one of us gives up hope - bam, pandemic.

So I was surprised (not really) to learn that we currently have 3 influenza strains circulating in Iowa (H3N2, H1N1 and Influenza B). From what I gather, there is a good match with the vaccine. So perhaps now would be a good time to get vaccinated.  As Dan said, we are doing well at UIHC with a 93% vaccination rate. Not sure what the vaccine uptake is in the community, but I guess we are about to find out.

Chicago Tribune article

Cigarettes = Acinetobacter+Pseudmonas+Staphylococcus

Researchers at the University of Maryland investigated the bacterial metagenomics of four brands of cigarettes and detected 15 classes of bacteria in all cigarette samples.  Holy Smoke! (couldn't resist)  The research by Saplota et al, just published in the March 2010 issue of Environmental Health Perspectives, found Acinetobacter, Bacillus, Burkholderia, Clostridium, Klebsiella, Pseudomonas aeruginosa, and Serratia in ≥ 90% of all cigarette samples and also Campylobacter, Enterococcus, Proteus, and Staphylococcus.

The authors point out that earlier studies had found some of these same bacteria on fresh tobacco leaves suggesting that contamination might be occurring at the farm or production level.  Other data has shown that certain bacteria, M. avium, can survive the burning/smoking process and infect the lungs. Perhaps this suggests that some other organisms (e.g. Bacillus or Clostridium) might also be able to survive. Of course more research is needed.  Fascinating stuff and isn't it great to know that in this age of instant access to information, that it only took me 9 months to find this study!

h/t Mark Vander Weg

Monday, December 6, 2010

Expand contact precautions? NO!!!!!!!

The Associated Press has an article today on infection prevention efforts at the University of Maryland Medical Center (Eli's old stomping ground). One of the interventions noted is universal contact precautions in the surgical intensive care unit. My thinking on control of multidrug-resistant pathogens is actually moving in the opposite direction. I think that high rates of hand hygiene compliance (particularly if coupled with standard precautions and a bare-below-the-elbows approach) will be shown to be as effective as contact precautions. Another useful approach may be universal gloving (we have found that to be as effective as contact precautions in the ICU setting). And I really don't think it's reasonable for family members to be required to wear gowns if they are not visiting other patients. However, the article's description of the white coat as a "walking germ" was great!

Friday, December 3, 2010

Style over substance

There's a new paper in the New England Journal of Medicine that looks at the rising importance of amenities in hospitals (full text here). For anyone who spends their professional life working to improve the quality of patient care, this paper will drive a knife through your heart. According to the authors of this paper, patient surveys reveal that the nonclinical experience is twice as important as clinical reputation in choosing a hospital. Let's hope that hospital administrators don't start trading in infection preventionists for monogrammed bathrobes!

Thursday, December 2, 2010

Take me home, country roads, to the place….

…where hospitals can decide for themselves how to vaccinate their workers against the flu. Sorry, those lyrics don’t really work. Still, West Virginia has decided against a statewide mandate for healthcare worker influenza vaccination.

I’m not sure this is big news, as I am not aware of how many states have decided to step into this issue—I had assumed that most would leave it up to each hospital. Maybe someone can enlighten.

I am blogging about this for two reasons. First, and most importantly, because West Virginia is Mike Edmond’s home state (or at least he went to college and med school in West Virginia). Here is a photo of Mike as a child, before he decided to pursue a career in medicine and was more interested in the banjo. Second, I wanted to report that our hospital is now at a 93% influenza vaccination rate without a mandate. If you recall, last year our shiny new mandate went down in flames after SEIU filed an injunction. So I’m especially proud of the fact that our healthcare workers are stepping up to be vaccinated without being forced to do so by threat of termination.

Two new NPSGs from the Joint Commission target VAP and CAUTI

University of Iowa, Class of 2013
The Joint Commission has just released new National Patient Safety Goals for 2012-13 for full implementation by January 1, 2013.  They cover VAP and CAUTI in hospitals and LTCF and are open for public comment until 1/27/2011.  The strategies were published in the October 2008 SHEA Compendium in ICHE. 

Two comments: (1) I thought the world was going to end in December 12, 2012, so probably not much to worry about, apart from the world ending and (2) VAP may be going away in NHSN to be replaced by process measures, so I wonder how VAP outcomes will be tracked, as required, when no one can decide on a definition? I'm sure you have comments and they want to hear from you.

Note: It looks like even if the Mayans were wrong about 2012, we may still not make it through 2013.

Example for VAP, NPSG.07.06.01 in Hospitals requires 7 steps:
1) A plan
2) Hand hygiene before/after caring for ventilated patients
3) Semirecumbent position of patient
4) Regular antiseptic oral care
5) Daily weaning assessment
6) Daily sedation interruption
7) Measure VAP process measures and outcomes

Hospital Program draft versions of NPSG.07.06.01 (VAP) and NPSG.07.07.01 (CAUTI) (PDF)
LTC Program versions (PDF)
JC page that provides links for submitting comments.

h/t Marc Wright

A surgical site infection enhancement bundle?

A new paper in the Archives of Surgery evaluated the implementation of a surgical site infection (SSI) prevention bundle for colon surgery (see free text of the paper here). The bundle contained the following components:
  • Omission of mechanical bowel preparation
  • Preoperative and intraoperative patient warming
  • Increased concentration of inspired oxygen during and immediately after the surgical procedure
  • Limiting intraoperative intravenous fluid volumes
  • Use of wound barriers to protect the surgical wound from contamination during the procedure 
Each component of the bundle was supported by 1 or more randomized trials demonstrating reduction in SSIs. About 200 patients were randomized to receive either the bundle or standard care. SSIs were determined by IPs using CDC case definitions. The study was terminated after a planned interim analysis revealed a <1% chance of showing a positive effect of the bundle were the study to continue to the accrual goal.

The overall rate of infection was 35%. In the control group, 24% of patients developed an SSI vs. 45% in the intervention group (p .003). In multivariate analysis, the bundle was shown to an independent predictor for SSI (RR 2.49, CI95 1.36-4.56).

I was struck by the very high rate of infection in this study, so I looked at CDC's most recent surveillance report, which shows that the mean pooled infection rates for colon surgery depending on risk category ranges from 3.99% to 9.47%. The authors postulate that their case ascertainment may be greater since the study was performed at a VA hospital where outpatient follow-up of patients is much easier to track. However, even in light of that, the rate still seems quite high. But on the other hand, unless there is something very unique about these patients or the care provided at this hospital, you might think that an effective prevention bundle would have even more impact in a setting with exceedingly high infection rates. This raises more concern that the bundle was not just ineffective but actually increased the risk of post-operative infection.

This paper is another example of how immature implementation science remains. I think the authors of this paper are correct to conclude that bundles of evidence-based interventions need to be formally tested before there is wide spread implementation.

Needed: CLABSI tune-up

We have blogged before about problems with NHSN HAI case definitions. For central line associated bloodstream infections (CLABSI), a major problem is the lack of specicity of the definition, which many believe leads to an overestimation of the rate of these infections. In this month's Infection Control and Hospital Epidemiology there is a commentary on the CLABSI definition by Dan Sexton that is well worth reading. He proposes some simple changes to the definition that would make a big difference in improving specificity.

Wednesday, December 1, 2010

World AIDS Day

We have mentioned a lot of Days recently.  Apart from perhaps Earth Day and traditional federal holidays, World AIDS Day is one day that I actually 'observe.'  Like last year, this year's theme is Universal Access and Human Rights.  If you want to read more, I suggest you head over to the PLoS Medicine blog where Nathan Ford from Medicine Sans Frontieres discusses the progress of the past decade and the problems ahead in the fight against AIDS.