Monday, January 31, 2011
Friday, January 28, 2011
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.
Tuesday, January 25, 2011
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?
Sunday, January 23, 2011
I've added his blog to our blogroll, and embedded his placebo video below. Warning: his language is somewhat colorful.
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.
Friday, January 21, 2011
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.
Thursday, January 20, 2011
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.
Tuesday, January 18, 2011
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
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.
Monday, January 17, 2011
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.
URMC Press Release
h/t Mark Vander Weg
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!)
Saturday, January 15, 2011
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.
Tuesday, January 11, 2011
|Madame Suzanne Necker|
Source: Wikimedia Commons
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.
Monday, January 10, 2011
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; email@example.com
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
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; firstname.lastname@example.org
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:
Source: Vancouver Sun and FDA MedWatch
|Paul Offit (on the right) with H Fred Clark|
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)
Sunday, January 9, 2011
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….
Friday, January 7, 2011
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
Thursday, January 6, 2011
Wednesday, January 5, 2011
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.
Liu C. et al CID Feb 1, 2011 (full text of Guidelines)
IDSA Press release 1/5/2011
Tuesday, January 4, 2011
| || |
Reduce infection or colonization due to specific pathogen(s)
Reduce all infections
Selective or universal
Application of a technology
Modification of HCW behavior
Exceptionalism (some organisms are more important than others)
Present / short-term
Present & future / long-term
Mandating influenza vaccine for HCWs
Bare below the elbows
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.