Thursday, March 31, 2011

David Livermore fights NDM-1, the 'super' superbug

David Livermore and NDM-1
There is a new story at highlighting David Livermore, NDM-1, and the myriad of reasons for the expansion of MDR-bacteria and hospital infections: little investment in antibiotic discovery and infection prevention.  I like this quote from the article in regards to infection prevention: "If it is done properly, it can ease the demand for drugs in the first place."  Dr. Livermore is the Director of the Antibiotic Resistance Monitoring & Reference Laboratory (ARMRL) at the HPA Centre for Infections in London. The story is surprisingly well-written, includes the usual human-interest angle and quite long but worth a read.

h/t Mark Vander Weg

Wednesday, March 30, 2011

Treating KPCs? - Eat Yogurt? NOT

CNN's advice for KPCs? - Eat Yogurt
In a recent piece on CNN, Elizabeth Cohen discusses the recent KPC outbreak in SoCal.  She offers some advice to patients and families as to how they can help prevent these 'superbug' infections under the heading "sorting fact from fiction."  Let's go through this: 1) Wash hands - check  2) Remove unnecessary catheters - check  and ....3) Eat Yogurt.?!?  What the?  To be fair, when she was challenged by the other news person, she backed off and said yogurt prevented some infections and not specifically KPCs, but why include it in the graphic?  Was yogurt the fiction to the hand hygiene fact?  Is the data even suggestive that yogurt "prevents" C. diff? Maybe this is a case of powerpoint making us stupid because she felt the need to have at least three bullet points per slide?

A study in Altern Ther Health Med from 2005 found no benefit of a non-dairy probiotic on the gut microflora including Klebsiella. The CNN article quotes my long lost co-fellow Mitch Schwaber, who was the author of the Israeli KPC outbreak that we highlighted last week. Hopefully Mitch will be in Dallas and I can ask him about the yogurt...

Serratia marcescens outbreak: Alabama

There is a new outbreak linked to TPN feeds in Alabama.  There have been 19 cases with 9 deaths due to Serratia marcescens contamination at 6 Alabama hospitals.  The  outbreak was identified on March 16th and the product manufactured by Med IV was subsequently recalled.  I wonder if this is too late for a SHEA late breaker...

BBC News 3/30
AOL News 3/29
CNN story from 3/29

See you in Dallas: SHEA 2011

Safe travels to anybody heading to Dallas this week for SHEA 2011 (and everyone else too). We hope to see some of you there. If you're unable to make it to Dallas, SHEA is offering on-demand webcasts with audio AND video.  This is the last year (for the foreseeable future) for a stand-alone SHEA meeting, as the meeting will be combined with IDSA in the fall of 2012. Change is change.

the New York Times is dead to me

Dan, Mike and I have frequently posted on content from the NY Times. As most of you have heard, on Monday the NY Times began charging for digital content.  This is the so called pay wall or pay fence or pay sponge. I have no problem paying for digital content as I subscribe to the Economist, National Geographic, etc on my iPad with specific apps or through Zinio, which is a great app if you haven't tried it. What troubles me with the Times current plan is that they are charging me based on what device I use to read their content.  I mainly read the NY Times (and everything else) on my iPad and phone.  With other digital subscriptions this doesn't matter since I pay a single amount and can access on any device. For example, the Economist charges $110 for a year subscription no matter how I read their content. The NY Times, however, has decided that they will charge $15/4 weeks ($195/year) to read on a phone and an additional $20/month ($260/year) to read the same content on an iPad, for a total of $455/year.  Crazy.

I know there are work arounds like linking off Facebook or through google searchs, but do I really want to do that?  I could also enter my username and password each time and just read on the iPad browser, but that is not the point.  I know I could subscribe to the Sunday Times for $8/week ($416/year) and save $39, but I don't really want to kill trees and waste fuel and this option isn't available in all places.  It is almost like they don't realize there is a digital age upon us.  Netflix doesn't care if I stream on a TV, laptop, or phone and why should they? Do they have extra reporters giving me inside information that only goes to my iPad? No!  There is almost no additional cost (marginal cost) for them to upload the same content to my iPad or phone, so it makes no sense for me to spend $260/year for something that costs them nothing.  They need to join the 21st century and not race back to the past. I thought the Times was called the Gray Lady since it had few pictures, but perhaps there is another reason. So, until they offer one price for digital access, the Times is dead to me.  I won't read (all bookmarks and apps removed) and I won't review, link or comment on NY Times generated content.


Economist online subscription page (so you can see what the world could look like)
WBUR's On Point has a great discussion on this subject that you can listen to.

Tuesday, March 29, 2011

Measles in Minnesota

So there is another measles outbreak, this time in Minnesota. Unlike recent experience with mumps, in which outbreaks are associated with vaccine failure (over 60% of cases occurring among recipients of two mumps vaccines), measles outbreaks occur primarily among the unvaccinated, and are sustained by those who reject or avoid the MMR (see prior posts here and here). Of the 13 confirmed Minnesota cases, 5 were too young to be vaccinated, 6 should have been vaccinated but were not, and 2 so far are of unknown vaccine status. Regular updates can be found on the Minnesota Department of Health website. There’s also an interesting article in the Star-Tribune about resistance in the local Somali community to receipt of MMR, out of fears of….you guessed it, autism.

We’ve covered this ground before—go here for our prior posts on the anti-vaccine movement. We recently had some local news coverage of a pediatrician who was declining patients if the parents refused vaccinations. I believe this is a perfectly reasonable position for a pediatrician to take. In fact, if a pediatrician does accept anti-vaccine families, he or she has a duty to warn all the other patients in the practice of the increased risk to infants or immunocompromised children from being in that office waiting room.

Is your hot water hot enough?

There's an interesting paper in the March issue of Emerging Infectious Diseases that examines water cultures from homes of patients with nontuberculous mycobacterial infections (full text here). This paper caught my eye because it's our perception at VCU that we're seeing more patients with pulmonary atypical mycobacterial infections. Curiously, we rarely see Legionella, another waterborne pathogen.

In this study, water samples were obtained from 31 NTM-infected patients' homes from across the US. 59% of the homes had NTMs found in the water, and 46% had matching species. Of note, patients whose hot water temperature was <125° were two-fold more likely to have contaminated water than those whose water was >130°. The author recommends that patients at risk of NTM infections (slender elderly persons and cystic fibrosis heterozygotes), crank up the heat on their hot water tanks.

Monday, March 28, 2011

A Brief History of VCU

Michael Edmond and Richard Wenzel
Virginia Commonwealth University (VCU), located in Richmond, Virginia, is a growing and vibrant university, but little is known about how it got to be so big and succesful.

1838: Medical Department of Hampden-Sydney College opened in Richmond

1854: Richmond Department of Medicine broke away from Hampden-Sydney College and became the Medical College of Virginia

1968: A merger between the Richmond Professional Institute and the Medical College of Virginia formed the existing VCU

1995: Drs. Richard Wenzel and Michael Edmond leave the University of Iowa to join the VCU faculty. Their combined efforts improved the quality of care, quality of life and life-span of all Virginians. Thus, more people want to live in Virginia and enroll in VCU.

2011: VCU "stuns" Kansas 71-61 making the NCAA Final-Four in Basketball.
Number of Final-Four appearances by the University of Iowa since Drs. Wenzel and Edmond left for VCU: zero (just saying)

1) wikipedia VCU page
2) Richard Wenzel's VCU page
3) Michael Edmond's VCU page

Sunday, March 27, 2011

Pronovost on HAIs

Photo: Johns Hopkins Medicine
There's an interview with Peter Pronovost on reducing healthcare associated infections in tomorrow's Wall Street Journal. You can view it here.

Worms and Germs

Scott Weese, DVM, DVSc
Photo: U. of Guelph
There's a great blog, Worms and Germs, that I would like to point out to our readers. I'm surprised that I had not previously seen it. It's written by Drs. Scott Weese and Maureen Anderson. Dr. Weese is a veterinarian and Chief of Infection Control at the Ontario Veterinary College Teaching Hospital. I have heard him speak a few times and have found his talks really informative and interesting. The blog focuses on zoonotic diseases and a link to it has been added to our blogroll.

Saturday, March 26, 2011

The blog turns 2!

Two years ago tomorrow, I had a meeting canceled and found myself with the unexpected gift of a few free minutes. Mike and I had been talking about starting an infection prevention blog, so I typed “how to start a blog” into The Google. Twenty minutes later, I posted for the first time. I can’t believe we’re still at it, and with a steadily increasing readership.

Mike and Eli can comment on what drives them to blog, but I know my initial motivation (one that Mike shared) was that there was no other venue in which to express timely and unvarnished opinion about the hottest topics in infection prevention. Publication turnaround times are slow, and even opinion pieces are often peer-reviewed and edited to the nth degree of blandness. One formative experience for me was having a letter to the editor of one of our major infection control journals rejected—not because it contained erroneous information or was poorly reasoned, but because it would give “aid and comfort” to those who didn’t share the dogmatic views on MRSA control held by the editor-in-chief.

Many of my early posts, then, involved me getting some things off my chest. For example, my day one post, entitled “Why I hate contact precautions, Vol. 1” (because I fully intended, and did, proceed with follow up posts containing additional reasons that I hated them!). Once some of those things were covered, including some memorable exchanges around the MRSA active surveillance debate, I found that the blog served many other important functions. Over time it has become a kind of “online catalogue” to which I refer frequently when writing proposals and manuscripts. It also keeps me on the lookout for interesting and useful items in our literature, and forces me to assess papers a tad more carefully than I used to—not just to see if they are “bloggable”, but to determine when there are flaws that ought to be pointed out to our readership.

I hope to spend time at SHEA next week talking with Eli and Mike about where to go with this blog over the next year. Feel free to make suggestions in our comments section or by e-mailing one of us directly. Most of all, thanks for your interest in this blog, and in preventing HAIs.

Friday, March 25, 2011

Blaming the health care worker: KPCs in Ireland

Mike posted yesterday about KPCs in LA, and now there is a report of a KPC outbreak in Ireland. I have read several reports of the outbreak, which involved 5-7 patients (two infected, three colonized) at the Mid-Western Regional Hospital in Limerick, and there is one consistent aspect to what is reported:  It's the health care workers fault. See the article "Hospital Staff Warned" in the Irish Times.

The articles state that "steps had been taken to improve hand hygiene standards among hospital staff but warned that a zero-tolerance approach was being enforced in respect of anyone who failed to comply with these standards" and that "This will include disciplinary action and or notification to relevant professional registration bodies if warranted in any particular case." 

Mike has written before about the dangers of this adversarial approach to infection prevention, so I won't belabor the point.  However, when the authorities state that they are already doing everything right since MRSA and C. diff prevention efforts are all you need to control KPC, I get a bit worried.  There is no evidence that this one-size-fits-all approach works for infection prevention.  Yes, compliance with infection prevention is important, but there must be other approaches besides punishing the health care worker that will protect our patients. 

The larger problem is that little to no research funding is available to study the epidemiology and optimal prevention methods for Gram-negative (or Gram-positive) bacteria.  Before we blame the health care worker, perhaps we could ask why there is almost no funding for infection prevention research and implementation and why there are no new antibiotic classes in the pipeline.  You do get what you pay for...

Thursday, March 24, 2011

MRSA infections declined in HIV+ patients

Dan and I have commented on the nationwide (and worldwide) decline in invasive MRSA infections.  Specifically we've discussed Alex Kallen's JAMA article from August 2010 that reported a continuous decline in invasive MRSA disease in the US from 2005 through 2008, including a 9.4% annual decrease in hospital onset and an estimated 5.7% annual decrease in health care–associated community-onset infections. We also mentioned there has been a 24% decrease in S aureus bacteremia in England and that recent European data demonstrates that more countries are experiencing decreases in the proportion of invasive S aureus infections caused by MRSA than are experiencing increases. However, what is happening with the MRSA epidemiology in high-risk populations, such as those who are HIV positive?

In a research letter just published online in AIDS, Alicia Hidron et al. from the Atlanta VA Medical Center analyzed MRSA infections in HIV+ patients during 2002-2009.  Infections were classified by NHSN criteria and community-onset was determined using the 48-hour rule and CA vs HA-acquired was determined using antibiotic susceptibility phenotype. Over-all, there were 168 patients with 226 MRSA infections (25 bacteremia cases and 180 SSTIs) in the cohort. 94% were community onset and 70% had community-acquired susceptibility profiles. They reported the rates per 1000 patients.  I could explain more, but all you need to see is this figure:

More evidence of an MRSA decline. Caveats: small study, single center, no statistics, no mention of MSSA infections. The authors didn't say when the Atlanta VA started active detection for MRSA, but given that 94% of the infections were community onset, that is largely irrelevant, which is the whole point.  MRSA went up and then MRSA went down and this almost certainly had to do with the complex interaction between the bacteria (likely USA 300) and the patients (immunity).  When you see reports that the VA's MRSA natiowide initiative worked, remember this study.

KPCs in LA

In the previous post, we learned from Eli that MRSA is going away. But there's no rest for hospital epidemiologists. The LA Times reports today that in the last 6-months of 2010 there were more than 350 cases of carbapenemase-producing Klebsiella pneumoniae infections reported from healthcare facilities in LA County. The epicenter appears to be long-term care facilities. Given the lack of treatment options for these pathogens, this is a very disturbing development.

Wednesday, March 23, 2011

A more cultured approach to fecal transplant?

Mike recently blogged about the increasing interest in fecal transplant for severe and/or refractory Clostridium difficile associated disease (CDAD). The procedure remains very slow to catch on, though. Why? The lack of a controlled trial is certainly one reason, but the other is simply the “ick” factor. The ick factor, and the difficulty in controlling a trial when another person’s stool is the deliverable, is also one reason why controlled trials have been slow to come.

If only one could replicate the stool microbiome using culture techniques, this barrier would exist no longer. However, early studies of the gut microbiome revealed that the majority of species are not cultivatable in the laboratory.

So I found this report from Washington University to be very interesting—these researchers were able to preserve gut microbiome functions in germ-free mice using strict anaerobic culture techniques. If indeed a person’s “readily cultured bacterial community” could exhibit in vivo behavior that mirrors the complete microbiome, then there is the potential for complex microbial communities to be developed and passaged that could replenish the microbiome in patients with CDAD.

Monday, March 21, 2011

Do Contact Precautions Cause Depression?

STOP Contact Precautions?

Mike has written several time about his concerns for the side-effects of contact precautions. (see his kill contact precautions, personal view and adverse effects posts). His post "adverse effects" discusses Dan Morgan's systematic review that looked at the state of the literature measuring what has become dogma for many hospital epidemiologists and clinicians: contact precautions harm people. After completing this review, we weren't entirely comfortable with the literature, so we set out to complete our own series of studies seeking to assess the association between contact precautions and adverse outcomes. 

The first such study by Hannah Day, a PhD student working with Dan Morgan and me, has just been published in the March 2011 AJIC.  It was a pilot study that allowed us to gather baseline estimates to complete power calculations for the larger studies that will follow. She measured the baseline levels of depression and anxiety in patients admitted to non-ICU wards of an acute-care VA hospital. Of note: this study was a sub-study within an MRSA prediction-rule study that we'd published earlier and Dan Morgan posted on a few months ago. (see Veteran's Day MRSA post)

In 2009, 103 patients (20 on contact precautions and 83 unisolated) were approached within 48 hours of admission and received a questionnaire that included a body of questions called the HADS - Hospital Anxiety and Depression Scale. What did she find?  The HADS score was 2.2 points higher in patients on contact precautions (p=0.21).  The odds ratio for having either depression or anxiety was nearly twice as high on contact precautions (OR=1.87, 95% CI 0.61-5.69).  Yes, the study was under powered.  Intriguingly, the increased HADS scores associated with contact precautions exposure was higher in those patients newly isolated (<1 year since first isolated).

Before everyone gets too excited, what does a HADS score difference of 2.2 mean? Well, this study was too small to determine whether this increase was due to depression or anxiety.  Additionally, with the combined scale, a minimum difference of 3.0 is considered clinically significant.  Thus, even if there is an association, it may have little clinical meaning.  Finally, the HADS was measured on admission, so we were unable to determine if isolation "caused" the depression. To do that, we would need to do repeated measurements on admission and throughout the stay to see if there was a change in HADS later in the admission.  More exciting data to come...

Day HR et al. Am J Infect Control March 2011

Sunday, March 20, 2011

Weekend fun

Many readers of this blog know Dick Wenzel, the legendary hospital epidemiologist. Several months ago he published his first novel. Now he has forged new territory. This weekend he appeared in Richmond's Dancing with the Stars. He performed the Argentine tango (see photo) and won the award for most dramatic performance. Is there anything this man can't do?

Addendum, 3/21/2011:  Here's the video--

Friday, March 18, 2011

More calls to eliminate the white coat

Mike has posted several times recently on white coats as vectors for the transmission of hospital pathogens.  William W. Motley, a PhD candidate at the NIH and the University of Oxford, has a nice post in the PLoS Medicice blog titled: "Are White Coats Turncoats?"  I suggest you read the full post, but have pasted my favorite sections below:

I realize that gaining the trust of a patient is an important part of effective doctoring and that this uniform helps instill confidence...But I hope that my communication skills (learned in medical school and before) and knowledge will be more effective tools than an infrequently laundered coat.

I think that more medical schools should start welcoming students with a stethoscope ceremony. White coats are superfluous uniforms; stethoscopes are important diagnostic tools. Stethoscopes also symbolize an even better way to gain the trust of a patient: by listening to them, and by listening to the evidence.

I agree, as long as the stethoscopes are cleaned between exams. (insert smiling emoticon)

Thursday, March 17, 2011

Regional Control of a large KPC outbreak: The Israeli Experience

The oubreak DID NOT occur here.
However, it IS St. Patrick's Day.
Hello everybody.  I hope you're all having a great St. Patrick's Day and a great Match Day.  Not sure those two days should be combined, at least for the safety of the future of the medical profession, but for some reason, that decision is not left up to me...

There is a report out electronically in CID (scheduled for April 1) by Mitch Schwaber et al. that describes the containment of a country-wide, carbepenem-resistant Klebsiella pneumoniae outbreak in Israel.  The outbreak of a highly-resistant strain, typically susceptible only to gentamicin and colistin, began in 2006 in multiple Israeli hospitals. The resistance was mediated by KPC-3 and local efforts to control the outbreak were largely unsuccessful. By March 31, 2007 there had been 1275 patients in 27 hospitals affected (13,040 beds).

In March 2007, the Israel Ministry of Health implemented a 3 component intervention: 1) Mandatory reporting of every patient with a carbepenem-resistant Enterobacteriaceae (CRE); 2) mandatory contact isolation of all known CRE carriers within self-contained nursing units in single rooms or cohorts with dedicated equipment AND dedicated nursing; and 3) creation of a nationwide task-force with statutory authority to intervene as necessary to control the outbreak.

Did it all work?  Well, they probably wouldn't have published this if it didn't work. They'd still be working too hard trying to stop the problem!  From the peak of 185 cases (56 cases/100,000) in March 2007 (92% of CREs were Klebsiella) infections fell to a low of 45 (12 cases/100,000) in May 2008, a 79% decline. I have pasted the incidence curve below. So it worked, but there are still too many CREs. If they let their guard down, the outbreak could easily reoccur.

As far as the study design, the usual caveats apply.  Despite great statistical control, they did not include a non-equivalent control group, etc, so perhaps these findings could be partially explained by regression to the mean or other biases, such as non-recorded interventions. Do I think that is what is going on here?  No.  I think the nationwide effort probably worked and their analysis and interpretation are correct.  This overwhelming response might be needed more often in the future given the lack of new antimicrobials, poor overall support for infection control (everywhere, not just in Israel) and continued overuse of the antimicrobials we do have.

Note: Dan posted on the CDC Guidance for Carbapenem-Resistant Enterobacteriaceae a couple years ago.

Gym associated vaccinia infection

Last week Eli blogged about a study where investigators tried to find MRSA in a gym and couldn't. Now there's a new paper in Emerging Infectious Diseases detailing a vaccinia outbreak (4 cases) associated with a gym  in Maryland. The source of the outbreak was never determined but some members of the gym were in the military. Fortunately, none of the infected had severe complications. But it begs the question: why should anyone be vaccinated with a live virus for a disease that has been eradicated?

Wednesday, March 16, 2011

15th Annual Fellows Course in Hospital Epidemiology & Infection Control

The original Washington Monument
The 15th annual Fellows Course in Infection Control & Hospital Epidemiology will be held July 6-8, 2011 in Baltimore. The course meets the ABIM requirements for ID fellows and is sponsored by SHEA. Faculty from the University of Maryland, Johns Hopkins, Brown, Wake Forest, U. Penn and Washington University are involved.  This is a really great 3-day course for anyone interested in evidence-based infection prevention  - it's not just for fellows. Discount registration is available before July 4th.

Baltimore is the largest independent city in the US.

for more info: SHEA course page, agenda, registration.

Tuesday, March 15, 2011

Go Epicenters!

The CDC just announced ongoing funding of the Prevention Epicenters (PE) program. You can read John Jernigan’s post at Safe Healthcare for the details. We have been involved in this program in the past (the University of Iowa participated during the first two rounds, and both Sloan-Kettering and Maryland were Epicenters while Eli was in those locations). Loreen Herwaldt worked with our Iowa group to put together a great application for this round. Alas, we fell short—but to a group of sites with real depth in the science and practice of healthcare epidemiology.

Collaborating within a multicenter research consortium has its challenges, and progress often seems painfully slow. It’s impressive, then, to look at the body of work that has come out of the PE program, especially given the shoestring budget from which it has been funded. Ten million dollars sounds like an awful lot of money, but spread over 5 centers (each of which represents a healthcare system) and 5 years, minus the institutional overhead, it doesn’t leave much to do studies that might lead to new insights in prevention. Too often this means scaling down prospective interventional trials into less-definitive-but-still-valuable observational studies, simply for want of funds.

Stacked against the morbidity, mortality and cost of health care associated infections, HAI prevention research is massively underfunded. The PE program is a great example, but should be scaled up 10-100 fold.

The white coat: Is it really going away?

There's an essay in by Rahul Parikh, a pediatrician in San Francisco, on the disappearance of the white coat. He postulates a number of reasons for this and draws parallels to the decline in public opinion of physicians. In essence, patients aren't dazzled anymore by the magic of the white coat as they have become more empowered and participatory in their care. All of this is good in my opinion. But I wonder if Dr. Parikh's observations may have a geographic bias. While the coat may be disappearing on the west coast, it's still alive and well on the east coast. Many trends move from west to east, so maybe in a few years, they'll disappear here too.

Saturday, March 12, 2011

Critique of the WHO pandemic response is now out

We blogged early and often about the H1N1 pandemic, including posts about the controversy surrounding the WHO response and whether there was any industry influence at play. An independent expert panel has now released a draft report on the 2009 H1N1 response. Here are the media summaries from the NY Times, Science Magazine, and the Nature blog The Great Beyond.

Regarding the industry conflict-of-interest (COI) issue, the report takes WHO to task for poor handling of COI and lack of transparency, but concludes that there is "no evidence of attempted or actual influence by commercial interests on advice given to or decisions made by WHO." I’m not sure what such evidence would be required…direct cash payments to members of the WHO advisory committee? Anyway, given that the panel felt that WHO waited too long to call the pandemic, it is unlikely they’d conclude that this decision was driven by industry COI.

Read the report yourself—now that Iowa has thawed out and the sun has appeared, I have no time to detail all 15 of the recommendations the panel made.

Wednesday, March 9, 2011

2nd ASM-ESCMID Conference on MRSA in Animals

"Am I not destroying my enemies when I make friends of them?"
Just a quick note that ASM has announced the date/location of the 2nd ASM-ESCMID Conference on Methicillin-resistant Staphylococci in Animals. The chair of the conference is Iowa's own Tara Smith.  The conference will be held September 8-11, 2011 in DC.  Abstracts are due June 17th.

Meeting Page: 2nd ASM-ESCMID Conference on MRSA in Animals

No MRSA on Gym Equipment!?!

Modern Torture Devices
Some days when I'm tired, I don't feel like going to the gym. As someone who follows the IC literature, I always had a ready excuse for myself and others if I didn't want to go.  Too risky!  I don't want to catch MRSA, haven't you read the papers?

So I was depressed when I saw the headline this morning about a new study in AJIC from the University of Florida that found no MSSA and no MRSA on gym equipment surfaces before or after routine cleaning. They sampled 3 gyms (private, high school and university) on 3 separate occasions and obtained 240 samples. They swabbed gyms mats, benches, dumbells, cardio machines and weight machines. Oh well, back to the drawing board...and back to the gym.

Kathleen Ryan et al. AJIC March 2011

The Suncoast News - March 9, 2011

Monday, March 7, 2011

National Patient Safety Awareness Week

This week is National Patient Safety Awareness Week. I especially like the AskMe3 campaign, a health literacy initiative that aims to improve patient-provider communication by encouraging patients to ask three basic questions of their healthcare providers:

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

I think we should each ask ourselves these three questions every so often.

The opposite of why we blog...

To be honest, sometimes when I read great posts like Dan's today on public reporting or Mike's on MRSA mandates, I get a little sad.  How can we possibly turn the tide against such well intentioned but misguided efforts. Just because at first pass something makes sense, doesn't actually support the contention that it actually makes sense, if that makes sense.  It should really come down to the science.

Initially, I wanted to comment, but then decided it might be better to just sit back and enjoy the show.  This feeling usually doesn't last too long. but it is nice to take a break, occasionally.  So for today and for the next few days, I'm going to enjoy imagining a world where we swab everyone, everywhere for every possible organism - linezolid-resistant S. aureus - check; ampicillin-resistant E. coli - check, etc etc and where we publicly report everything to everyone even if we don't validate what we are reporting.  This seems to be where we are going with infection prevention in the US, so I might as well get to the future now.  I'll let you know what it's like when I get there.  Wish me luck.


From those who brought you “getting to zero”

Here’s a comment that has received an unusually robust response on the Emerging Infections Network:

My hospital system plans to do blood cultures on all patients who are admitted with a central line in place (decision not yet final, but momentum is great). Such cultures would prevent mis-labeling of community-acquired infections as hospital-acquired, if infection actually happened to be present on admission and was not clinically suspected. This would allow upgrade of DRGs, to increase reimbursement, and would prevent a CLABSI from being labeled wrongly as hospital acquired. Our state has mandatory reporting and comparison of CLABSI for all hospitals and there is great pressure to reduce rates. I have great reservations about this practice, having seen this done before when blood contaminants stalled the entire purpose of the admission, adding to antibiotic use and length of stay. Does anyone else have opinions or experience with this practice?
So just to be clear: as a result of pressure to get their publicly reported rates of CLABSI to zero (and to maximize reimbursement), this hospital plans to obtain admission blood cultures on every patient with a central venous catheter. Not only will these non-indicated cultures drive up healthcare costs, they will result in untold days of unnecessary antibiotic use (for the blood culture contaminants that will greatly outnumber true pathogens), increase pressure for antimicrobial resistance, prolong hospital stays, and could result in potentially lethal adverse effects (drug reactions, C. difficile, etc.).

Happy Monday!

Sunday, March 6, 2011

Berwick is out

Looks like Don Berwick’s tenure at CMS will be a short one, since the votes to confirm him are not there. We commented here on his initial recess appointment. I can’t comment much more without making this a political blog, which has never been our intent. I will only say that it is a sad commentary on the state of our divided government, and yet another setback for efforts to improve the U.S. healthcare system. As for a replacement: who in their right mind would want to step into this arena now, to have their record judged by people whose primary goal is the failure of healthcare reform?

Bundle the baby

There's a new paper in Pediatrics that evaluates implementation of central line insertion and maintenance bundles across all referral NICUs (n=18) in New York state. Surveillance for infections followed NHSN methodology and evaluated a 12-month period prior to implementation of the bundles to a 10-month period after the bundles were implemented. Overall, there was a 40% reduction in CLABSI. Higher volume NICUs demonstrated lower infection rates and less variation in performance. For each standard deviation increase in maintenance checklist usage, there was a 16.5% decrease in CLABSI rate. However, the authors point out that "in light of some agencies’ considering CLABSIs to be “never events,” it is important to note that no NICU achieved an overall CLABSI rate of 0."

Saturday, March 5, 2011

The world is their Petri dish

The average person harbors at least 10-fold more bacterial than human cells. So I smile whenever I read articles like this one. I guess we're supposed to be shocked, just shocked, to find that densely populated human environments are, well…..not sterile.

Given the range of behavior displayed in public transit systems (245 complaints of urinating and defecating in one year? really??), it makes sense to design the environment with surfaces that are easily cleaned and disinfected. Routine efforts to document microbial contamination in such environments are mostly a waste of time and money. Call me if you’re planning such an effort in your municipal transit system. For half the cost, I’ll predict with uncanny accuracy what you’ll find…..