Happy Halloween!

Maggie and Alicia

 

Nothing better than infection prevention related Halloween costumes.  I'm still trying to imagine Mike dressed as a flu vaccine, but its a bit difficult.  Anyway, here in Iowa City Maggie dressed as a collection of hospital pathogens clinging to Alicia, a contaminated textile.  Good times.

Science Friday: Influenza Vaccine Debate

Mike Osterholm, PhD MPH

Earlier this week, Mike posted his thoughts on the recent Lancet ID review of influenza vaccine efficacy.  This week's Science Friday featured a "debate" between Mike Osterholm, one of the authors, and Bill Schaffner. The discussion covers several important topics including the utility of influenza vaccine in seniors.

Click here to listen to the mp3 audio (full hour, but the vaccine discussion is first up)

Source: Science Friday (NPR, Talk of the Nation)

Needle-free flu vaccine? Not so fast!

On second thought. Maybe the hypospray did hurt?

Bummer.  We were getting so close to the Star Trek reality we always dreamed about.  We can now talk to our communicator-like, Siri-enabled iPhones and until this week, we could get a flu vaccine using a hypospray-like needle-less jet injector. Unfortunately, for your deltoids, FDA now recommends against the use of the intramuscular-labeled vaccine using jet injectors.  Only one vaccine, the MMR, is approved for use with the jet injector and the FDA hasn't received the safety and effectiveness data to approve other vaccines using this technology.

Note: This does not apply to the intradermal vaccine, which is supplied in its own pre-filled syringe.

Source: FDA Updated Communication on Use of Jet Injectors 10/26/2011 

It's a vaccine, not a miracle

There apparently was a recent rumor causing quite a stir in some segments of the infectious diseases community that a paper was about to be published that would show that influenza vaccine doesn't work. Well, the paper was published yesterday and the results don't quite match the rumor. Osterholm and colleagues have published a systematic review and meta-analysis on the efficacy and effectiveness of influenza vaccine in Lancet Infectious Diseases. The major finding was that the pooled efficacy of the vaccine is 59%. This is somewhat lower than that found by the Cochrane group (73% in years when the vaccine and circulating strains were well matched); however, there were some differences in methodology that are well outlined in an editorial that accompanies the paper.

Shocking? I don't think so. I have never thought that influenza vaccine was a great vaccine. It's a good vaccine; certainly good enough to widely recommend its use. But clearly not so good as to fire healthcare workers who refuse to take it.

Two years ago I blogged about the interview in the Atlantic with Tom Jefferson, the head of the Cochrane influenza group. Here's the money quote from that interview:

"For a vaccine to reduce mortality by 50 percent and up to 90 percent in some studies means it has to prevent deaths not just from influenza, but also from falls, fires, heart disease, strokes, and car accidents. That's not a vaccine, that's a miracle."

Headline of the day

This is my favorite headline about the demise of drotrecogin alpha (a.k.a. activated protein C, Xigris), which was withdrawn from the market yesterday after the PROWESS-SHOCK study results revealed it to be no better than placebo in the treatment of severe sepsis. The headline, of course, implies that Xigris once was effective, it just isn’t any more…and from the quotes in this story, it appears that Lilly is arguing that improvements in sepsis management have now made it impossible to detect the incremental benefit that Xigris provided (you know, back when we were super-terrible at treating sepsis).

Fair enough, but that explanation ignores the controversial history of this drug and the role of Eli Lilly in the surviving sepsis campaign. It also ignores one of the most important lessons we should learn from this debacle: the perils of the subgroup analysis. Eli, our in-house methodologist, may wish to chime in, but you can start here with a nice review that points out why subgroup analyses of clinical trials should be treated with extreme caution, and used only to generate hypotheses, not for clinical decision making (or drug approval!).

1 week to 7 billion

(AP Photo/Pavel Rahman): Bangladesh

7 billion people. Seven billion. Unimaginable. The UN Population Fund estimates by October 31, 2011, the world's population will be 7 billion. Only 200 years ago, there were 1 billion people on the planet and it took 150 years to get to 3 billion. The UN projects that it could grow to 15 billion by the year 2100.  I wonder if it will even be possible to control the emergence of resistant pathogens like NDM-1 if we don't first address the population crisis.

Atlantic Monthly has a wonderful series of photographs that highlight the population explosion and the secondary environmental impact.

My favorite comment below the photo series is "7 bil peeps can fit in an area 34x34 miles. Shoulder to shoulder back to front."  I don't know if this is true, but perhaps they can test it out on MythBusters.

h/t JJ Furuno

Encouraging antibiotic development: a grassroots effort

Dear Readers,

I have just received this call to action from Dr. Timothy Walsh, Professor at Cardiff University, who I mentioned last week in regards to the NDM-1 crisis in India. Below is an online petition from the British Society for Antimicrobial Chemotherapy (BSAC), that I would urge you to sign. The petition will be presented to 10 Downing street (British Government) on the 9th of November followed by a garden reception to further articulate the crisis we currently face.

Antibiotic Action

Securing the future of antibiotic development …. determined to make a difference

www.antibiotic-action.com


New antibiotics are urgently needed for use now and in the future

No antibiotics – no chemotherapy | No antibiotics – no transplant surgery | No antibiotics – no hip/knee replacements | No antibiotics – no treatment for infectious diseases| No antibiotics – no heart surgery | No antibiotics – no cystic fibrosis treatment | No antibiotics – no kidney transplants

NO ANTIBIOTICS – NO CURE – NO CHANCE

The simple truth

Please join this global initiative - sign the petition on the website above.

Thank you.

Another nail in vanco's coffin

Photo: Old-Pictures.com

Eli's group, with Marin Schweizer as first author, has just published a retrospective cohort study in BMC Infectious Diseases (full text here) that addresses an important and relatively common clinical question: should we treat methicillin-susceptible Staph aureus bloodstream infections with vancomycin? Most infectious diseases experts agree that cefazolin or nafcillin are better for MSSA because these drugs provide better bactericidal activity than vancomycin. Nonetheless, vancomycin's pharmacokinetics usually allows for more convenient dosing. As more patients are being treated at home with IV antibiotics, drugs that require every four hour dosing (e.g., nafcillin) are much more difficult to use unless the patient is willing to use a small programmable pump that must be carried at all times. Vanco may be even more attractive in patients with renal failure since dosing becomes very infrequent. On the other hand, I am finding it harder to maintain therapeutic trough levels with vancomycin. In young patients with high creatinine clearances, I sometimes find that even every 8 hour dosing results in trough levels that are too low. Supratherapeutic troughs occur when renal dysfunction develops, which is not uncommon in acutely ill hospitalized patients. And it seems that as we push the levels higher we are seeing more renal dysfunction. So vancomycin drives me a little crazy.

But what did Eli find? In his cohort of 267 patients with MSSA bacteremia, those that were treated with cefazolin or nafcillin (including those who also received vancomycin) were nearly 80% less likely to die than those who received only vancomycin for the duration of their treatment. What about the common clinical scenario where vancomycin is started empirically then changed to cefazolin or nafcillin once MSSA has been identified? Those that were switched from vancomycin were 69% less likely to die than those who continued on vanco. Bottom line:  think twice before using vancomycin solely on the basis of convenience.

Predicting the future

There's a perspective in this month's Emerging Infectious Diseases on carbapenemase-producing Enterobacteriaceae (full text here). For the most part, it's a well written piece that focuses on the geographic spread of these organisms. Near the end, however, the authors make a pitch for active surveillance:

The prevention of spread of carbapenemase producers relies on early detection of carriers. Patients who undergo screening should include patients who were hospitalized while abroad and then transferred to another country, and patients at risk (e.g., patients in intensive care units, transplant patients, immunocompromised patients). Screened patients should be kept in strict isolation before obtaining results of the screening (at least 24–48 hours). Because the reservoir of carbapenemase producers remains the intestinal flora, fecal and rectal swab specimens are adequate for performing this screening. 

Yikes! If I followed their advice my hospital would probably be doing a few hundred tests per week. I'll leave the thorny problem of what test to do to Dan, our blog's microbiologist. But more active surveillance means more contact precautions. And we love contact precautions!

Photo: Managed Care Matters

So let me look into my crystal ball and predict the future for our readers:

• A diagnostic testing company will develop a rapid test for the detection of these organisms
• The diagnostic testing company will become a strategic partner to A Group that Represents Infection Preventionists (AGRIP)
• AGRIP will survey all of its members on whether they have ever seen such organisms in their hospitals
• A paper will be published along with a press release revealing the shocking news from the survey that these organisms are much more prevalent than anyone ever imagined
• The strategic partner (bless their heart!) will help AGRIP educate the infection control community and the public on the dangers of this horrible organism
• I'm a little fuzzy on this prediction, but there may be a second survey
• States will pass laws requiring testing of patients admitted to hospitals to protect their citizens from the horrible organism
• The strategic partner will hire a new vice president and all will live happily ever after

I will now put the crystal ball away, return to my regular life as a horizontalist, and simply scream, WASH YOUR HANDS, PEOPLE. WASH YOUR HANDS!!!

Don't poo-poo it!

Photo: People's Pharmacy

There's a new systematic review in Clinical Infectious Diseases on intestinal microbiota transplantation (AKA stool or fecal transplantation) for Clostridium difficile infection. In scouring the literature, the authors found reports of 317 patients who had received this treatment with an overall success rate of 92% and no attributable adverse effects.

Stool transplantation was first performed in a human in 1958; however, veterinarians have used this treatment for hundreds of years in treating horses with chronic diarrhea. The vets call it "transfaunation," which I think sounds better than what we call it.

I first became interested in this treatment when I began getting patients referred to me who had had numerous episodes of C. difficile infection over long periods of time despite treatment with every known pharmacologic intervention. I've now done 10 or so transplant procedures. Unfortunately, the systematic review does not describe the duration of diarrhea that patients endured prior to transplantation, but in my experience, patients have often had diarrhea for months. A few months ago, I successfully transplanted a patient who had diarrhea for six years every time oral vancomycin was discontinued. And what's most amazing about this treatment is the rapidity of its effect--most patients have resolution of symptoms within 24 hours. One patient called me to say that she screamed with delight on having her first normal bowel movement in 6 months just 1 day after her transplant.

When I explain the procedure to patients, I always give them the option of doing the procedure themselves at home (a DIY paper was published last year), but when I get to the part about the blender, the patient invariably cuts me off with a big "NO!".

There are still skeptics, however. The purists say they would never perform such a procedure without results of a randomized controlled trial reporting effectiveness. Of course, publication bias may be at play here, making the procedure appear more effective than it truly is. But I think that being a good doctor sometimes forces you to confront the limits of evidence, step outside of your comfort zone, and try a therapy that's cheap (particularly when you consider that a 2-week course of oral vancomycin costs about $2000), probably effective, and safe when appropriate precautions are taken. And there's an argument to be made that when a treatment has a dramatic effect (a rapid response on a stable background), the risk of bias accounting for that effect is very low.

For those of you who want to read more, there's an excellent, recently published, perspective piece in Clinical Gastroenterology and Hepatology that nicely reviews the rationale and methods for performing the procedure.

Some good news for a change...

Photo: Robert JR Graham.com

This week CDC announced progress made on reducing healthcare associated infections. Analyzing 2010 data from the National Healthcare Safety Network, CDC found:

• A 33% reduction in central line-associated bloodstream infections (35% reduction in ICU patients and a 26% reduction in non-ICU patients). 
• A 7% reduction in catheter-associated urinary tract infections throughout hospitals
• A 10% reduction in surgical site infections
• An 18% reduction in the number of people developing health care-associated invasive MRSA infections

"Young" doctors and vaccines

Vaccines these days can't catch a break.  Back in the day when people were dying from polio and measles, everyone (including physicians) could see the benefits of vaccines first hand. Now, with the success of vaccines in the bag, the ground has shifted against vaccines from "seeing is believing" to "what have you done for me lately." 

There is an abstract at IDSA that reports that young physicians are less supportive of vaccines. Sara Kliff at the Washington Post reports that Michelle Mergler (Emory) and Saad B. Omer (Johns Hopkins) found that recent medical school graduates were “more likely to believe immunizations do more harm than good" and were 15 percent less likely to believe vaccines work. Bummer.

see also: Shari Roan, LA Times 10/20/2011

100 to 200 Million with NDM-1 in India

Dr. Timothy Walsh, Cardiff

We've continued to follow the emergence of NDM-1 around the globe.  A recent interview in the Times of India that Tim Walsh gave was an interesting read and very concerning.  Walsh is the lead author of the recent Lancet ID paper that Dan commented on earlier this year which reported NDM-1 bacteria in 4% of drinking-water samples and 30% of waste-water samples in New Delhi.

Most concerning was his suggestion "that the carriage rate of NDM-1 in India is between 100 and 200 million" people.  Crazy.  The interview is a great read since he pulls no punches.


Source: Times of India, October 9, 2011

The last IDSA...for a while?

Everyone around here seems to be off to IDSA.  This is the last IDSA before a whole gamish of societies  (IDSA+SHEA+HIVMA+PIDS) becomes IDWeek.  In honor of all of my ID colleagues headed to Boston, I offer the following cartoon.  I think ID physicians are doctors among doctors, we just aren't reimbursed as such. Have fun and look both ways.

Pee first, then think!

Photo: Run On!

At the gym today I was reading the Chronicle of Higher Education while riding the bike and came across an article on the Ig Nobel awards. These awards are for research papers that first make people laugh, then make them think. One of the winners in the Medicine category went to the investigators who did a study published in Neurourology and Urodynamics on the effect of acute increase in urge to void on cognitive function (full text here). The study subjects drank 250 mL of water every 15 minutes until they could no longer inhibit voiding. Cognitive tests were performed hourly from baseline through extreme urge to void and then postmicturition. The investigators found that the extreme urge to void state was associated with significant declines in cognitive function that reversed after voiding.

Very interesting study, isn't it? So it got me to wonder whether Tom Talbot had to pee really badly when he drafted the SHEA position paper on flu vaccine for healthcare workers. Fess up, Tom!

Disclaimer:  Tom's a great epidemiologist and regular reader of our blog, so this is all in fun. 

You say meticillin and I say methicillin

Although not the "highest level" of evidence in the scientific literature, I often find the personal reflections of senior scientists very entertaining and often useful. One of my favorite in the genre was Robert Wise's 1989 reflections on nosocomial S. aureus published in RID/CID.  Barry Cookson has a similar reflection in the October 8 Lancet titled "Five decades of MRSA: controversy and uncertainty continues."

Barry labels each decade of MRSA research and control with interesting titles. For example, the 1970s were the "decade of complacency" while the 1990's were the "decade of dawning realization." He sprinkles in personal anecdotes, etc and echoing what Dan and I wrote in JAMA last year, he ends with a spot-on conclusion:

"However, my major concern is that, with the downturn in the economies around the world and reductions in MRSA, there will be a tremendous temptation to reduce the funding of prevention and control measures. It is vital that policy makers and governments realise that they must continue to spend money to save money. MRSA and other hospital infection pathogens will continue to pose threats to patient safety in the foreseeable future. One thing is certain: the response to these challenges will determine the next decade of research and reaction to MRSA."

Hear hear!

Source: Cookson B, Lancet 2011 (378): 1291-2.

Abstract of the Year?

I know this isn't HAI related, but it did have me dreaming up abstracts for some of my projects...

This is a real paper that can be found here.

h/t JJ Furuno and the incidental economist

Factoid of the day

1 in 6 cell phones is contaminated with fecal bacteria (read about it here).

Photo: Wired

Climate change and hospital pathogens

Do hospital pathogens like living in a Greenhouse?

Nothing should dare threaten your coffee.  So when Starbucks announced today that global climate change is threatening coffee supplies, you knew it would get media attention. What's a journalist without their coffee and cigarettes? (aaaack) What about hospital pathogens? Could climate change impact hospital infection rates. We thought it might. (Note: by we, I mean my colleague from Maryland Judy Johnson - She's now in Gainesville).

Back in 2006, Judy and I were sitting on a park bench (it was a nice day) discussing the upcoming ICAAC abstract deadline and pondering what we should submit, when she suggested we look for seasonal variation in Gram-negative pathogens.  Judy mentioned some data suggesting Gram-negative infections were more common in tropical countries and we also discussed the high incidence of Acinetobacter infections in troops returning from Iraq. Sure, we also knew that others had noticed summer peaks in certain pathogens, but the prior research didn't control for meteorologic factors and also combined summer data from across the entire US (hint: Maine ≠ Texas). Thus, we felt there was room for further exploration.

In our initial analysis, published in ICHE (2008), we reported that summer season (vs. winter) was associated with 28% more P. aeruginosa, 46% more E. cloacae, 12% more E. coli and 21% more A. baumannii clinical cultures over 8 years. Importantly, we found that for each 10°F increase in temp, there was a 17% increase in the monthly rates of infection caused by P. aeruginosa and also A. baumanii. Of course, this was a single center study, so we needed more proof.

Mike Eber and our group have just published a follow-up study in PLoS One looking at BSI data from 132 hospitals over 8 years. Using 211,697 inpatient blood isolates, we again found that Gram-negative organisms were more frequent in summer months ranging from 12.2% higher rates for E. coli to 51.8% higher for Acinetobacter spp. And more interestingly, we reported that independent of season, monthly humidity, monthly precipitation, and long-term trends, each 10°F rise in mean monthly temperature was associated with higher Gram-negative bacterial BSI frequencies ranging between 3.5% for E. coli to 10.8% for Acinetobacter spp.  Thus, warm temps = more Gram-negative bacteremias; that is, even a warm winter is a bad thing.  Lots more work to do to figure out why this might be, but I think it's an interesting first (or second) step. Cheers.

Note: Special thanks to Ramanan Laxminarayan and Extending the Cure for supporting this project.

Good riddance!

I’m so happy to see this flawed performance measure dropped. I think I’ll take a 5 minute break to write a blog post, then another 5 minute break to stare out the window and marvel that a measure with such toxic unintended consequences was actually abandoned!

h/t to Edward Goodman, via a post on the EIN this morning.

Chart of the day

The figure below comes from a new study in PLoS Medicine using data from the European Antimicrobial Resistance Surveillance System (EARSS) to model expected trends in bloodstream infections due to MRSA and 3rd generation cephalosporin resistant E. coli (G3CREC) in Europe. Click here for the free full text of the paper.

Bathrooms and Infections

Maryn Mckenna (Colin Purrington started the meme) has an nice post on bathroom design and infection risk on her SuperBug blog.  One thing I was not aware of was that hot air hand dryers "pull air from the bathroom floor, not from the outside, so all they’re doing is shooting a blast of hot bacteria full force onto your hands. One study showed that using electric dryers increased bacteria levels on hands by 162 percent.”  It's all pretty scary.  I think alcohol hand rub is the answer.  I like how O'Hare airport in Chicago has alcohol hand rub dispensers just outside each bathroom.

Oh, if you like the signs on the hot air dryer and door, just download Purrington's door signage and hand dryer signage files (PDFs) and print onto 4 x 6″ 3M removable adhesive labels (#6200). Thanks Colin and Maryn!

Flu shot: Just take it on faith

Photo: Media dis&dat

The Journal of Hospital Infection has just published a systematic review on the effectiveness of seasonal influenza vaccination in healthcare workers. Here's the money quote from the abstract:

No evidence can be found of influenza vaccinations significantly reducing the incidence of influenza, number of ILI (influenza like illness) episodes, days with ILI symptoms, or amount of sick leave taken among vaccinated HCWs.

It's important to remember, however, that absence of evidence for the vaccine's effect, is NOT evidence of absence of an effect. I'm getting my flu shot this week, but I'm taking it on faith.

WHAP VAP in 8 easy steps

We’ve covered this before…..how difficult it is to define VAP, how easy it is to reduce rates without improving outcomes, etc. Well, now Michael Klompas has published a handy guide entitled, “Eight initiatives that misleadingly lower VAP rates”. You’ll need a subscription to AJIC to read it, but it is a compelling document. I’m disappointed that he couldn’t come up with just 2 more, to make it a “top 10” list. How about adding: “lie”, and “make 'infinity' the new denominator”. That was easy!

Hand hygiene in the emergency department

ICHE has an interesting paper up on hand hygiene (HH) in the Brigham and Women’s emergency department. As part of a QI program, the ED deployed 5 trained observers and an infection preventionist to performing HH audits for 16 months. Impressively, they covered all days of the week, and all shifts (much of our data on HH comes from weekday first-shift observations, which may differ from what one might find on weekends or at night). The overall adherence was good, at ~90% (the observers were known to the ED personnel, but this is still an excellent rate of HH). The most notable findings included (a) physicians had slightly higher adherence than nurses, which runs counter to the conventional wisdom, (b) transport personnel had the lowest adherence (<70%), and (c) hallway location (which by definition translates to an overcrowded ED) was associated with lower adherence (82%, compared with 91% in a private room).

Because I’m always on the lookout for more reasons to despise contact precautions, I immediately seized on this last finding. As Mike and his colleagues pointed out in a study published in March of this year, difficulty in finding beds for patients requiring contact precautions is one factor that exacerbates ED overcrowding. At Mike’s hospital, patients who required contact precautions waited in the ED for an hour longer than those who did not. Active detection and isolation programs make this problem even worse, as pointed out in this Irish study—patients colonized or infected with MRSA waited 2.5 hours longer in the ED than did those who were not identified as being at high-risk for MRSA.

In other words, not only does ED overcrowding lead to poorer HH and increased risk of pathogen transmission, but the patient population in many EDs may be “enriched” with MDRO carriers (who stay in EDs longer while awaiting a bed)!

"New hospital will be superbug free"

Rendering of the new University Hospital of North Staffordshire
From:  NHS Stoke on Trent

The title of this post is actually the title of a newspaper article that appeared today in the UK. Hospital officials claim that in this new building "MRSA will be eradicated," and even though patients may bring in C. difficile from home, "its chances of spreading once in wards and departments will be zero." The article extols the virtues of a new hospital with more private rooms, and the CEO of the hospital proclaimed "we will have the capability to eradicate hospital associated infections."

Really?

These comments are either incredibly naive, blatantly dishonest, or APIC-speak (i.e., we know this actually can't be achieved, but it's an aspirational goal). Regardless, it's another example of getting-to-zero run amok.

Your dirty laundry

Photo:  Mary Ann's Cupboards

There's a new paper in Infection Control and Hospital Epidemiology that includes a series of experiments designed to evaluate the effectiveness of laundering scrubs in your home washing machine. This is important since most healthcare workers who do not work in the operating room launder their own scrubs at home, and some hospitals even have OR staff wash their scrubs at home as a cost-savings measure. The major difference between home and hospital laundering is water temperature--hospital laundries typically use water temperatures of 160°F, whereas home washing machines are generally set to deliver water temperatures at 60-80°F (cold), 90-110°F (warm), or >130°F (hot).

Key findings were:

• Hot water (140°F) with or without detergent was highly effective in killing MRSA and Acinetobacter.
• Warm water (104°) with detergent was highly effective in killing MRSA and Acinetobacter. Without detergent, warm water was still highly effective against MRSA, but only moderately so against Acinetobacter.
• When clothes are washed with warm water but no detergent, they become contaminated with gram-negative organisms (Klebsiella, Enterobacter, Serratia) from the washing machine's biofilm, though washed clothes are largely free of gram-positive skin flora.
• When fabric swatches that were inoculated with Acinetobacter were ironed (on the iron's highest setting) with a contact time of at least 7 seconds, the organisms were killed.

So warm or hot water with detergent is your best bet (though I have to wonder who washes their clothes without detergent?). I do iron my scrubs, though many people don't, but I'm sure that my ironing contact time is less than 7 seconds, and some scrub fabrics can't tolerate the iron's highest setting.