SHEA Program Planner is now live

If you haven’t yet made plans to attend, please consider coming to Dallas on April Fool’s Day to attend the SHEA 2011 scientific meeting. You have two months to review the scientific abstracts that will be presented, as the online program planner is now up!

Friday feces blogging (part 3)

or why the MSM is sometimes full of **itself...

You may have seen the headlines the past few days:

Sleeping with pets exposes owners to nasty diseases, paper says (LA Times)

Out of the sack, cat! Sleeping with pets carries disease risk (MSNBC.com)

Sleeping next to pets could be harmful, study says (USA Today)

Well. Let's talk this through.  The headlines are all discussing a recent EID paper to be published in February 2011.  The review article by Bruno Chomel and Ben Sun is well written and thorough and discusses the infections that have been linked to pet exposure including plague and even MRSA.  They cite interesting facts such as 60% of households have pets. Does my Pet Rock (TM) count? 56% of dog owners sleep with their dog next to them. 62% of cats slept with their adult owners and 13% slept with the children in the house!! Armageddon!

So lets look at the risk.  For MRSA they cite one case of MRSA transmission from a dog to a man and his wife.  Once the dog was decolonized - boom - recurrent MRSA infections ceased.  Now, did the dog give it to the owners or did transmission go the other way?  Perhaps dogs shouldn't risk sleeping with people, not the other way around. So 60 million pets, one case of MRSA.  Pretty good odds.

Discussions of other diseases (e.g. Rabies!) are less helpful for us, particularly in the US with high levels of vaccination.  To be fair to the authors, they didn't intend to spark fear and their primary recommendation is that pet owners should seek regular vet care of their pets to reduce the risks.  Sound advice.

But the MSM has gone too far I think.  Suggesting that Fluffy should be kept next to the bed and not in the bed is ridiculous.  The data just doesn't support it; at least not the data provided in the EID article.  I think a better bet would be to recommend that people not share the same bed.  I bet there has been far more MRSA and TB not to mention STDs spread between humans that share the same bed.  Now I know why Lucy and Ricky slept apart!

update: the writer of this post has never lived with a dog or cat due to allergic family members.  he was thinking of getting a dog now that he lives far from the allergic family members.

Friday feces blogging (part 2)

Since Dan had to go and bring up the subject of feces, I would like to direct our readers to a new article in Slate on fecal transplantation for C. difficile. Although Slate is written for the general public, this article does a good job explaining the procedure and the controversy that surrounds it. Of course, the issue of lack of randomized trials to support this intervention comes up in the article. I would respond by asking this question:  if you had diarrhea for 6 months unresponsive to treatment, would you try it, or would you wait for an investigator to perform a trial and publish it before you agree to giving it a try? And the other interesting question is whether randomized trials are always needed. On that one, I'll point you to an interesting paper in BMJ from a few years ago.

Friday feces blogging

Some blogs reserve Friday for “pet blogging” or “cat blogging”, featuring cute photos of cuddly animals. Perhaps we should also highlight animals on Fridays…..so I’ll start with pigs. An article in BMC Microbiology is poised to tell you what you may already surmise: that flies and cockroaches on pig farms share gut bacteria with the pigs. This study looked specifically at enterococci, characterizing antimicrobial resistance phenotypes and genotypes, virulence determinants, and using PFGE to link strains from roaches, flies and pigs.

Targeting zero credibility?

I have written before about the unintended adverse consequences of an inability to be honest about HAI prevention, and Mike recently blogged about “aspirational goals” and reality. At the end of his post, Mike linked to an inspiring news story about the success being achieved at the City of Hope, among the sickest of patients. A telling quote from this piece demonstrates how “zero talk” can not only motivate, but also demoralize those who are on the front lines of infection prevention:

"It's tough, especially when there is a lot of literature out there that talks about zero infections….I think there should be zero infections. But not all health care-associated infections are preventable.”

As if on cue, I got an e-mail today from Bard Access Systems APIC, announcing the roll-out of a new website entitled, “I Believe in Zero CLABSIs”. Zero is no longer an “aspirational goal” for Bard Access Systems APIC, but a very concrete one:

“We not only believe in Zero CLABSIs — we know it is possible, and we are confident that the tools and resources contained on this website will provide you with the framework you need to help your facility BELIEVE and ACHIEVE ZERO CLABSIs.”

If APIC is unwilling or unable to speak honestly about HAIs, they will eventually lose credibility with their members who fight daily to prevent them. Furthermore, insisting that zero is already achievable weakens the rationale to perform the kind of groundbreaking translational research that is needed to push CLABSI rates ever closer to an irreducible minimum. Why investigate novel approaches to prevention if we already know how to eliminate every CLABSI?

Bad Science

Yesterday, my wife forwarded me a video on the placebo effect. Since I teach that topic to the first year medical students in their epidemiology course, I felt compelled to take a look. And I discovered Ben Goldacre, a British psychiatrist, who I think could best be described as a translational epidemiologist/comedian. He writes a column in The Guardian newspaper and a blog, both entitled Bad Science, all about, well, bad science. He likes to focus on media misrepresentations of medical studies, attempts by the media to scare the public about various health issues, and the corrupting influence of pharmaceutical companies. Interestingly, his father, Michael Goldacre, is the Chair of the Department of Health Care Epidemiology at the University of Oxford.

I've added his blog to our blogroll, and embedded his placebo video below. Warning: his language is somewhat colorful.

Aspirational goals

There's a paper in the February issue of Infection Control and Hospital Epidemiology by a group of investigators at the University of Pennsylvania. They set out to perform a systematic review of the literature to determine the proportion of healthcare associated infections that are reasonably preventable. Their determination was that 65-70% of central line associated bloodstream infections and catheter-associated urinary tract infections were reasonably preventable, and that 55% of ventilator-associated pneumonia cases and surgical site infections were reasonably preventable. Quick, someone call APIC--they're still targeting zero! I know, I know: zero is an aspirational goal. And I'm still aspiring to be a professional football player.

Addendum, 1/23, 9:55 AM:  I just ran across this article published yesterday in a California newspaper. Now here's a piece that's apropos, and one that tries to tell the other side of the story.

Learning to count...

There's an old joke about asking an accountant "what's 2+2?" and the accountant responds "what do you want it to be?"

Unfortunately, CDC has some creative math rules of its own. So for hospital epidemiologists, 1 + x = 1 when it comes to counting central line days. That is, for patients who have more than one central line, only one line can be counted per day for the denominator in calculation of central line associated bloodstream infection (CLABSI) rates. It's as if only one of the three central lines in the acutely ill ICU patient poses a risk to the patient. Magically, the other two are immune.

In the February issue of Infection Control and Hospital Epidemiology, there is a study by the Hopkins group that examined the effect of the one-catheter-per-day rule and found that counting only one catheter falsely overestimated their CLABSI rate by 36% in 3 surgical ICUs.

Two years ago, our group presented a very similar study at SHEA done in our medical and surgical trauma ICUs. We found that the CDC rule falsely overestimated our CLABSI rate by 20%.

In the era of mandatory public reporting of HAIs, it's imperative that everything be done to produce the most valid data for consumers. I'm baffled that CDC has been so slow to respond to these issues. The focus seems to be on validating surveillance using the methodology as is, rather than modifying the methodology to make it more valid.

Breaking down the CLABSI bundle

There is an interesting CLABSI prevention study out this week in PLoSONE (full disclosure: tireless co-blogger and pal Eli is one of the authors). In order to determine how well the CLABSI bundle was being implemented in U.S. ICUs, and which individual elements (or subsets of elements) were most strongly associated with CLABSI reductions, the authors surveyed NHSN hospital practices. They used quarterly ICU-specific CLABSI rates as their outcome measure.

The bottom line: the bundle was associated with lower CLABSI rates only for units that monitored and reported high rates of compliance with at least one element of the bundle out of three (maximum sterile barrier precautions, optimal site selection, and daily assessment of need).

Why would meticulous adherence to any one of these three bundle elements be significantly associated with CLABSI reduction, while meticulous adherence to all the elements was not? I believe it was a simple power issue: too few ICUs (only 38%) had high rates of adherence to the whole bundle. Lack of power could also explain why no single element was statistically-significantly associated with CLABSI reduction.

This study is a good first step toward “breaking down the bundle”, to determine which elements are most important for infection prevention, what compliance measurements are most useful, and (eventually) what components should be added, or subtracted, from existing bundles.

Don't Let the Patient RIDE THE BUS!!!

If you have a child under 10, you've probably enjoyed Mo Willems classic, Don't Let the Pigeon Drive the Bus!  I've never thought of it as a public health advice book for the Blue's Clues set, but perhaps I should have.

Researchers from Nottingham University wondered if exposure to public transport (bus or tram) within the most recent 5 days was a risk factor for acute respiratory tract infection.  They report in BMC-ID a small case (n=72) - control (n=66) study that riding public transport was associated with a 6-fold increase in presenting to a primary care physician with an acute respiratory infection (adjusted OR=5.94 95% CI 1.33-26.5).  Another interesting result was that it appeared that more frequent riding was associated with a lower risk of respiratory infection: (1-3 uses/week: adjusted OR=0.54, 95% CI: 0.15-1.95; >3 uses/week: adjusted OR=0.37, 95% CI: 0.13-1.06).

Some important caveats: (1) The unadjusted OR for public transportation was only 1.10, 95% CI: 0.55-2.21.  (2) To get to the adjusted OR, they controlled for age, gender, comorbidity, deprivation, child cohabitants, flu vaccination and habitual public transport use.  So, while the findings are intriguing,  negative confounders are extremely rare, so I think this study needs to be repeated.

Now off to read my favorite Mo Willems book: Don't Let the Hospital Epidemiologist Stay Up Late!

Troko J. et al BMC ID, published 1/14/2011

The Epistemological Problem with Comparative Effectiveness Research

We will be seeing an increasing investment in comparative effectiveness research (CER), much of which will go to connecting and mining pre-existing clinical datasets.

Are you excited by the prospect of mining massive clinical databases to determine which medical interventions are most effective?

Are you convinced that observational CER can provide answers to 48,000 key clinical questions that remain unanswered?

Well, Kant says it can’t. Sorry.

S. aureus vaccine breakthrough?

Researchers at the University of Rochester have just announced a potential breakthrough in S. aureus (MRSA) vaccine methods.  Edward Schwarz and John Varrone presented their new findings at the Orthopaedic Research Society annual meeting in Long Beach, Calif this past week.

Their work targets the S. aureus glucosaminidase (Gmd) protein, which is thought to act as a zipper by opening the bacterial cell wall during cell division. Importantly they discovered four anti-Gmd monoclonal antibodies that prevented growth in cell culture. They also demonstrated that mice treated with anti-Gmd antibody were half as likely to develop infection. Phase I human trials are planned for 2012.

References:
URMC Press Release

RSC Article

h/t Mark Vander Weg

Practical Wisdom - Why checklists and incentives might not be the answer

There is a "collective dissatisfaction" with our healthcare system; there are two types of responses we can make when things aren't going right - the first is that we can make more rules or checklists to follow, so that even if we don't care or know what to do, we can just follow the script. The other is incentives, so that even if doing the right thing isn't in our interest, we make it beneficial by providing carrots and/or sticks that encourage the best behavior.

We have spent the past several years attempting to prevent hospital infections using these same two responses: checklists and incentives (payment restructuring and public reporting).  While these efforts are well intentioned, each is fraught with problems.

Unfortunately, there are no sets of rules that can get us where we need to go.  Why? Because people can always find ways to beat the system or avoid the rules.  Barry Schwartz and Kenneth Sharpe through wonderful and insightful stories in their new book called Practical Wisdom, explain how the wise person knows when to and how to bend the rules to achieve the right thing.  Too many rules de-moralize the intelligent person and incentives create people that just follow incentives...

Their book (and the TED video below) are a kind of anti-Freakonomics and an anti-Checklist Manifesto.  It is not that they are telling us to get rid of rules entirely, but suggest that rules are not enough. Additionally, they suggest that when we live by incentives, they crush our ability to do the right thing.  Enjoy the video (if you aren't at a location that has a "rule" blocking TED videos!)

Bug-mobiles?

There's a new study in the American Journal of Emergency Medicine that caught my eye this morning. It asks the interesting question: are patients who present to the hospital via advanced life support (paramedic) transport more likely to develop HAIs than those who do not.

The design was a retrospective cohort which evaluated over 150,000 hospital admissions over a 5-year period at a hospital with a level 1 trauma center. The study found no difference in community-acquired infections between the two groups. However, patients arriving by ambulance were 1.4 times more likely to develop an HAI.

Since observational studies can be plagued with bias and confounding, we can't determine whether the ambulance transport led to the higher rates of HAIs. Nonetheless, as infection rates fall in hospitals, the identification of new groups at potential risk is important, since this can lead to the implementation of new interventions. As I begin to put together our annual report on HAIs, it's evident that we've picked the low-hanging fruit, and although rates of infections continue to fall, the slope of the curve is flattening. Thus, we need to return to the drawing board to develop new strategies.

Madame Necker lives on

Madame Suzanne Necker
Source: Wikimedia Commons

You are probably asking: Who is Madame Suzanne Necker? And what does she have to do with infection prevention? Well, she was the wife of a French finance minister who started a campaign in the late 1700s to limit the number of patients per hospital bed to 1. At that time, up to 8 patients shared a bed in French hospitals.

So the one patient-one bed standard came to be and has lived on. In 2006, over 200 years later, the American Institute of Architects Guidelines for Design and Construction of Health Care Facilities called for a new standard of one patient-one room. A 2008 commentary in JAMA outlined many reasons for the private room standard, including reduced potential for HAIs, reduction of patient transfers, enhanced patient throughput, and greater privacy for patients and families.

A new study in the Archives of Internal Medicine, looks at the acquisition of pathogens before and after the move from an ICU with multiple patients per room to a new ICU with all private rooms. Another hospital in the same city with the same infection control service and multi-bed rooms throughout the study period served as a comparator. The authors report that the acquisition of MRSA, VRE and C. difficile fell 54% after the move to the all private-room ICU. I think the study has a number of problems, which I won't belabor here, but will point out one curious finding that somewhat undermines the authors' conclusions--although the rate of MRSA acquisition fell after the move, the rate of MSSA acquisition did not.

Two years ago, all the ICUs at my hospital except one moved to a new tower with all private rooms, including our NICU. Clearly, it's easier to practice good infection prevention with patients separated nicely, though one downside that we noticed immediately was that it became much more difficult for our hand hygiene observers to collect as many hand hygiene observations from any single point of observation.

Bottom line: I think that private rooms probably do have an impact on reducing infections, though I don't think we have proven that yet. And whatever gains can be made by better design can probably be undone by poor compliance with hand hygiene.

Call for Algorithms: MRSA surveillance and pre-op antibiotics in cardiac and orthopedic surgery

I'm involved in an AHRQ-funded contract to identify and then study algorithms for SSI prevention in cardiac and orthopedic surgery. In an effort to expand our search for what methods others are using to prevent resistant Gram-positive SSIs, they asked that I post the call for algorithms here.  Our hope is that IPs or hospital epidemiologists could quickly send us their protocols. This study involves University of Iowa, The Joint Commission, AHRQ, and University of Maryland.  Thanks for your help!

Submit your hospital’s pre-operative algorithms and protocols for antimicrobial prophylaxis for patients with resistant Gram-positive organisms undergoing orthopedic and cardiac procedures

We are seeking examples of algorithms, protocols, pathways, policies and procedures, and standing orders that address selection and administration of antimicrobial prophylaxis for cardiac and orthopedic surgery patients. If your organization routinely screens pre-operative patients for MRSA, it would be helpful to also include screening and de-colonization algorithms and protocols.

The goal of this activity is to develop consensus-based algorithms for widespread dissemination that will contribute to reducing the rate of surgical site infections. This collaborative project, funded by the Agency for Healthcare Research and Quality (AHRQ), is being implemented by the University of Iowa, the University of Maryland, and The Joint Commission, with guidance from an expert panel of surgeons, anesthesiologists, and epidemiologists.

Please submit the information by fax or email to: Michele Bozikis at (630) 792-4922; mbozikis@jointcommission.org

Project Goals and Objectives
The goal of this project, "Optimizing Pre-Operative Antibiotic Prophylaxis for Cardiac and Orthopedic Procedures," is to determine whether a pre-operative antibiotic prophylaxis algorithm that includes the use (including selective use) of antibiotics shown to be effective against resistant gram-positive organisms is effective in reducing the number of surgical site infections (SSIs) attributable to resistant gram-positive organisms.

The objectives include:
1. Identify, through a review of the literature and existing studies, the most promising algorithms for pre-operative antibiotic prophylaxis for the prevention of SSIs in certain cardiac and orthopedic procedures
2. Develop one or more algorithms that incorporate the use (including selective use) of antibiotics shown to be effective against resistant gram-positive organisms
3. Design and conduct a study that compares the new algorithm(s) against standard algorithm(s) used for administering pre-operative antibiotic prophylaxis of SSIs in certain cardiac and orthopedic procedures

Future Opportunities
If additional funding is received, we will begin recruiting hospitals for participation in a study to test the effectiveness of the consensus-based algorithms at reducing SSIs. Recruitment will begin in Fall- 2011. Information will be shared as it becomes available. Stay tuned

For More Information
If you have questions about this project, please call Michele Bozikis at (630) 792-5922 or Joanne Hafner at (630) 792-5970; jhafner@jointcommission.org

Alcohol Swabs and Prep Pads Recalled for B. cereus

Triad Group has initiated a voluntary product recall involving all lots of sterile and non-sterile Alcohol PREP PADS, SWABS, and SWABSTICKS for possible Bacillus cereus contamination. To date these products have been linked to one skin infection. The recall involves the US, Canada and Europe.

The products can be identified by either “Triad Group,” listed as the manufacturer, or the products are manufactured for a third party and use the names listed below in their packaging:

Cardinal Health
PSS Select
VersaPro
Boca/ Ultilet
Moore Medical
Walgreens
CVS
Conzellin

Source: Vancouver Sun and FDA MedWatch

Paul Offit on Science Friday: The anti-vaccine movement

Paul Offit has a new book out called: "Deadly Choices: How the Anti-Vaccine Movement Threatens Us All."  He was on NPR's Science Friday last week to discuss his book and touch on the death and destruction caused by Andrew Wakefield's scientific fraud (see Brian Deer's BMJ report here) and other aspects of the anti-vaccine movement.

Some short clips from the 17-minute piece:



Paul Offit (on the right) with H Fred Clark

Ira Flatow mentioned that when Dr. Offit was on the program in 2008 a women called in and basically said "No amount of research, none of it, done by government or pharmaceutical companies could change her mind about vaccinating her children."  She said "I don't put any faith in anything my government tells me"

In the 2010 interview a caller said: given the "vast number of immunizations that you are requiring at such a young age that really is taking a toll on the immune system, I think that's just logic"

Paul Offitt responds by pointing out that 100 years ago there was one vaccine, the small pox vaccine with about 200 immunological components. Now there are 14 different vaccines in 26 doses and all of these vaccines combined have less components, perhaps 160 immunological components, than the single small pox vaccine.  He also went on to explain how this is not mercury (no longer in kids vaccines). Even with this evidence the caller said "I'm not hearing anything that sounds credible to me as an educated adult."

And that's the concern.  The anti-vaccine movement is a shifty "business".  First it was vaccines = autism.  After numerous studies that showed NO link, they moved on to mercury.  When mercury was removed, they continue to blame it even though it is not there!  Now it is the number of vaccines, which is irrelevant.

If it was the number of vaccines that was causing the problem then Paul Offit points out that we would all be dead.  We are exposed to many more viruses, bacteria and other onslaughts than could possibly be given via vaccines.  But it is silly to argue.  This is not a discussion you can have, nor is it logical, but rather a symptom of the anti-scientific movement. If people don't believe science, you can't convince them with science...

This past weekend's All Things Considered touched on the same topic but they put a more positive spin on the recent developments.  I have posted a link to their piece titled: "As The Facts Win Out, Vaccinations May, Too," below.  Seth Mnookin, a contributing editor at Vanity Fair, discusses his book "The Panic Virus: A True Story of Medicine, Science, and Fear" and the deadly impact that the anti-vaccine movement has had.


Science Friday with Ira Flatow (1/7/2011)

Direct link to interview with Paul Offit on Science Friday (mp3)

All Things Considered (1/9/2011)

What to do with a vancomycin MIC?

In response to a spate of papers suggesting that elevated vancomycin MICs within the susceptible range are associated with poor clinical outcome, many clinicians now reflexively change to alternative therapy (daptomycin or linezolid) for treatment of any MRSA isolate with a vancomycin MIC of 2 mcg/mL. The most recent such paper can be found here.

As a result of this evolving standard of practice, one particular section of the new IDSA MRSA treatment guideline is generating discussion on our clinical microbiology listserv:

How should results of vancomycin susceptibility testing be used to guide therapy?

For isolates with a vancomycin minimum inhibitory concentration (MIC) ≤2 μg/mL (eg, susceptible according to Clinical and Laboratory Standards Institute [CLSI] breakpoints), the patient's clinical response should determine the continued use of vancomycin, independent of the MIC (A-III).

--If the patient has had a clinical and microbiologic response to vancomycin, then it may be continued with close follow-up

--If the patient has not had a clinical or microbiologic response to vancomycin despite adequate debridement and removal of other foci of infection, an alternative to vancomycin is recommended regardless of MIC.

For isolates with a vancomycin MIC >2 μg/mL (eg, vancomycin-intermediate S. aureus [VISA] or vancomycin-resistant S. aureus [VRSA]), an alternative to vancomycin should be used (A-III).

The bottom line? S is S, I is I, R is R. Treat the patient, not the MIC. If the patient is responding, good. If not, then you ought to be seeking alternatives, regardless of the exact MIC.

I agree with this approach for several reasons, not the least of which is that exact vancomycin MICs are method and laboratory dependent. In addition, +/- 1 dilution step in MIC is within the usual variability of our clinical laboratory MIC testing (MIC quality control ranges usually encompass 3 or 4 dilution steps). Even if every clinical microbiology laboratory did population analysis profiling of each MRSA strain, other treatment and host factors would likely have overriding impact on the clinical outcome.

Despite the fact that vancomycin is a bad (and mysterious) drug, we still lack alternatives that have been convincingly shown to be better for most MRSA infections….

MRSA colonization: Is it a quantitative or qualitative relationship?

Leonard Mermel

Few studies have assessed the importance of quantitative differences in MRSA carriage at various body sites. Len Mermel et al. from Warren Alpert Medical School (Brown) has a new study out in the Journal of Clinical Microbiology that assessed the relationship between quantitative burden of MRSA colonization at various body sites and colonization at other sites. For example, if patients are heavily colonized in the anterior nares, are they more likely to be colonized elsewhere and carriage at which sites are related to heavy nares colonization?

In a cohort of patients known to be MRSA+ during the prior year, the study team collected swabs from the each nares, each axilla, each groin site, and the perineum. Swabs were tested for presence of MRSA using CHROMagar plates and log10 colony counts. 

In this known MRSA+ cohort, 53 of 60 patients were MRSA+ at at least 1 site and 29/123 cultures were only positive after broth enrichment.  75% (40/53) were colonized extranasally. Sensitivity ranged from 91% in the nares, 63% in the groin, 47% in the perineum down to 32% in the axilla. The greatest combined sensitivity was 98% for nares+groin.

Mean log10 counts were highest in the nares (1.95) and lowest in the axilla (0.87). As the colonization count increased in the nares, the number of distant sites colonized increased.  For each 1 log increase, the OR=2.1 for distant colonization. As far as risk factors, diabetes was associated with colonization in the perineum. One interesting finding was that mean log counts were lower in patients with a current or previous infection than in patients who had never been infected (1.6 vs 2.4, p=0.3)

Mermel LA et al J Clin Microbiol 2011

Headline of the day

To read the piece from CNN, click here.

IDSA Releases MRSA Treatment Guidelines

Perhaps to celebrate the 50th anniversary of MRSA's discovery in 1961, IDSA just released their first MRSA treatment guidelines. The guidelines don't discuss infection prevention strategies but rather focus on specific clinical questions such as "What is the management of skin and soft-tissue infections (SSTIs) in the era of community-associated MRSA (CA-MRSA)?"

A recommendation getting a lot of attention in the press is that you don't always have to treat MRSA with antibiotics. What! We treat viruses and pseudo-infectious syndromes with antibiotics, we should at least give antibiotics to patients with pathogenic bacteria even if they aren't needed. It's only fair! (sarcasm alert) The press attention focuses on the first recommendation in the document that says "For a cutaneous abscess, incision and drainage is the primary treatment (A-II). For simple abscesses or boils, incision and drainage alone is likely to be adequate, but additional data are needed to further define the role of antibiotics, if any, in this setting."

My favorite section deals with "Research Gaps" such as whether vancomycin should be the first drug of choice for empirical therapy or should the patient also receive a β-lactam antibiotic to cover for MSSA? The guidelines also have a "Performance Measures" section that includes weight-based dosing of vancomycin combined with trough-monitoring.

Overall, for an almost 30-page guideline (not counting references), I found it very well written and organized. Nine of 15 authors (if I counted correctly) report COI. The guidelines were endorsed by the Pediatric Infectious Diseases Society, the American College of Emergency Physicians, and the American Academy of Pediatrics.

-Eli

Liu C. et al CID Feb 1, 2011 (full text of Guidelines)
IDSA Press release 1/5/2011

Religion & infection control: issue #5

I've written several posts about religion and infection control over the last few years. Now there's a new issue. My friend, Gonazlo Bearman, has covered it in a great post, so I'll simply refer you there.   

Developing your approach to infection prevention

I spent some more time recently thinking about horizontal strategies for infection prevention in preparation for an upcoming talk. The slide below compares and contrasts the differences between vertical and horizontal approaches.

	Vertical	Horizontal
Goal	Reduce infection or colonization due to specific pathogen(s) [pathogen-based]	Reduce all infections [population-based]
Application	Selective or universal	Generally universal
Interventions	Unipotent Application of a technology	Multipotent Modification of HCW behavior
Resource utilization	Typically high	Lower
Philosophy	Exceptionalism (some organisms are more important than others)	Utilitarianism
Values favored	Hospital	Patient
Temporal orientation/ perspective	Present / short-term	Present & future / long-term
Examples	MDRO ADI Mandating influenza vaccine for HCWs	Hand hygiene Bare below the elbows Chlorhexidine bathing Care bundles Reducing presenteeism

By the way, this talk is part of a virtual conference on February 15-16 sponsored by Infection Control Today. You can register for free here.