Friday, April 29, 2011

Blame them, shame them, and fire them! Or give them bonuses. Or something.

In part two of the NY Times “Fixes” blog piece on hand hygiene, Tina Rosenberg tackles the perplexing challenge of improving hand hygiene practices in hospitals. An excerpt from the summary paragraph:

“Health care workers have difficult jobs, and it is important for hospitals to take their views into account when they institute measures to improve hand-washing rates. But if it takes public posting of hand-washing rates and firing of individual doctors or nurses who don’t comply to bring down infection rates, it should be done.”

We covered this ground before, the proper role of reward versus punishment for influencing health care worker behavior. I would love comments from our readers on this. I’ll merely remind everyone that direct observation of “entry-exit” hand hygiene adherence, even in centers that do the most intensive monitoring, captures only a tiny fraction of HH opportunities. And entry-exit adherence is the tip of the iceberg. Try working an 8-hour shift as an ICU nurse while adhering perfectly to all “5 moments”.

Wednesday, April 27, 2011

Will Berwick survive at CMS?

Bob Wachter’s latest post gives me some (slim) hope that my earlier post about Berwick’s tenure at CMS being over was premature. Read for yourself—it seems like a double-bank shot to me, and the “political zombie” argument is a more plausible explanation for some of his recent statements. But who knows?

Wee bitty BABIES and their wee bitty SCABIES
You never want to see the words babies and scabies in the same sentence.  That's why I added 'wee bitty' so as to add as much distance as possible between them.  Come to think of it, you don't actually ever want to see scabies in a sentence - ewey ewey

In the May 2011 ICHE, investigators at New York-Presbyterian Hospital describe what appears to be the first reported scabies outbreak in a newborn nursery.  You can imagine that the typical 4-6 week incubation period seen with first exposure coupled with the fact that babies typically go straight to the nursery without leaving the hospital, keeps at least detectable scabies out of newborn nurseries.

In 2007 there were three cases of scabies over 3 months in infants born at the hospital, which were recognized by a pediatric dermatologist. Extensive investigation identified 7 additional cases including 3 NICU babies. And the cause was:

The team identified that one per diem nurse, had contributed to 10 of the 10 electronic medical records examined. Upon evaluation, she was noted to have a rash and wore a noticeably dirty compression glove for lymphedema while on duty, making it impossible for her to clean her hands effectively. She also reported that she had been treated for scabies at least 5 times in the previous year. During the same 7-month period as the cluster, she reported that she also worked in a Florida hospital’s nursery. The staff at the Florida hospital stated that they had identified a cluster of scabies in infants in their institution also.

At NYP Hospital, they found that this nurse had cared for 392 patients including mothers and a letter was sent to each patient describing the outbreak investigation. This process identified 3 additional cases. I agree with their conclusion that "a single case of scabies in a newborn should be considered a sentinel event of a nursery outbreak.

Ross BG et al. ICHE May 2011

Tuesday, April 26, 2011

Good news, bad news

Here’s a nice “good news, bad news” report by Becky Miller and colleagues from DICON (the Duke infection control network). First the bad news: Clostridium difficile has now replaced MRSA as the most common HAI in this 39 hospital network in the southeastern United States. The good news? This development is driven largely by a steady and substantial decline in healthcare-associated MRSA infections between 2005-2009. Check it out:

We’ve discussed this trend before, a trend documented by CDC investigators in the NHSN and EIN programs, and confirmed in the VA system as well. The challenge now is to find a way to make the C. difficile trend line resemble that for MRSA….

High tech hand hygiene monitoring

There is a new online commentary in the New York Times on the use of technology to improve hand hygiene compliance in hospitals. This piece, the first of two parts, appears in an online column called Fixes, which looks at solutions to social problems. Dr. Phil Polgreen from the University of Iowa is interviewed in this piece.

Monday, April 25, 2011

Accentuate the negative

Dan has posted previously on how difficult it is for authors to get negative studies published.  Perhaps this is the real reason why the STAR*ICU study took 4+ years to make it to press.  I suspect that if the study was completed the exact same way that it was but found a benefit for barrier precautions, it would have appeared in press around 2009 or even earlier.  Just a guess.

Mike has posted at least twice on Ben Goldacre and his blog/book called Bad Science (part 1 and part 2).  Ben has a new post in the Guardian that discusses how medicine, academia and popular culture all favor positive, eye-catching and potentially spurious trial results and ignore important negative studies.  His discussion centers around a paper published last year that seemed to provide evidence of precognition - you know it before it actually happens.  That "positive" paper received tons of press, while a new negative study can't see the light of day.  I think this sort of bias plays a large role in infection prevention research - it is so much easier to publish a positive quasi-experimental study showing a benefit than a negative study.  This is why it was so great that after 4+ years of waiting the STAR*ICU study, which was a negative study, was published at the same time as the VA study, which showed a benefit.  This way, we could have a rational discussion with the positive/negative evidence receiving "almost" equal billing.

Ben Goldacre "Backwards step on looking into the future" Guardian 4/23/2011

Getting soap to those who need it

The Starwood Hotel Group has entered into an agreement with Clean the World to recycle soap and shampoos from its hotels with the products donated to the developing world. It is estimated that as much as 1.6 million pounds of soap will be recovered yearly in this program.

What a cool program!

Saturday, April 23, 2011

Antibiotic resistance on the farm

Photo:  Jeff Roberson, Associated Press

Today's LA Times has a well-written article on the relationship between agricultural use of antibiotics and antibiotic resistance. You can read it here

Friday, April 22, 2011

FDA Warns: OTC products caught making false MRSA claims

Today, I was off searching the interweb for news at sites not named The New York Times, when I came across this piece in the LA Times. Apparently, the FDA has issued four warning letters to companies making false claims that their products prevent MRSA infection.  These products, which include some 'natural' hand sanitizers, had little data to back up these claims.  The companies/products include:
  • Tec Laboratories for Staphaseptic First Aid Antiseptic/Pain Relieving Gel;
  • JD Nelson and Associates for Safe4Hours Hand Sanitizing Lotion and Safe4Hours First Aid Antiseptic Skin Protectant;
  • Dr. G.H. Tichenor Antiseptic Co. for Dr. Tichenor’s Antiseptic Gel;
  • Oh So Clean, Inc dba CleanWell Company for CleanWell All-Natural Foaming Hand Sanitizer, CleanWell All-Natural Hand Sanitizer, CleanWell All-Natural Hand Sanitizing Wipes, and CleanWell All-Natural Antibacterial Foaming Handsoap
My recommendation:  stick with alcohol hand rub or just plain-olde soap-n-water (TM)

Source: FDA News Release 4/20

Quote of the Day

“How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.

What has gone wrong with us?”

From Patients Are Not Consumers

Thursday, April 21, 2011

Gut check

A European research consortium just reported their analysis of gut microbiome diversity in 39 individuals from Europe, Japan and the United States. The figure below summarizes their findings: that the “metagenomes” of fecal communities cluster into three recognizable “enterotypes”, each dominated by a different genus (Bacteroides, Prevotella, and Ruminococcus).

This must be important, because it was published in Nature and extensively covered in the media, right? Probably, but the meaning and importance of these findings await much more work to correlate health and disease states with the composition and function of different microbial communities. To my simple mind, these findings suggest that perturbing the gut flora with antimicrobial therapy likely has a wide variety of adverse consequences, most of which we don’t yet understand.

Until we learn more, we’ll have to be satisfied with some of the straightforward correlations that these investigators uncovered. For example, in the words of one of the authors:

"If I have a stool sample I can tell how old you are," says Bork. "That seems useless because you already know how old you are…”

SHEA 2012 and IDWeek 2012 - SAVE THE DATES

So there are now two new meetings to choose from if you're interested in infection prevention.  Dan and I are involved with the planning of both meetings, so as more information becomes available, I'm sure we will provide it to you, our dear readers and accidental web surfers looking for Snicker's pictures.

SHEA 2012: Advancing Healthcare Epidemiology & Antimicrobial Stewardship, April 13 - 16, 2012 in Jacksonville, FL

SHEA 2012 is not the same old SHEA.  The old scientific meeting with podium and poster presentations has merged with IDSA (see below).  This new spring meeting is newly designed for 2012 and offers both the traditional basic SHEA/CDC training course as well as a parallel advanced epidemiological methods track that focuses on designing, analyzing and presenting infection prevention research. The conference also includes meetings addressing antimicrobial stewardship.

More information when available will be posted on SHEA's website

Inaugural IDWeek 2012: October 17-21, 2012, in San Diego, CA
A Joint Meeting of IDSA, SHEA, HIVMA, and PIDS

IDWEEK 2012 is where to go if you want to see the latest science surrounding infection prevention.  The SHEA podium, symposium and abstract presentations are expected to run parallel to the traditional IDSA-infectious disease presentations so that attendees can choose what is best for them.

For more information visit

Wednesday, April 20, 2011

MRSA in veterinarians

Scott Weese's blog has a great piece on MRSA in veterinarians. You can view it here.

Fallor ergo sum - I err therefore I am

Kathryn Schulz is the author of Being Wrong: Adventures in the Margin of Error.

"One can't understand everything at once, we can't begin with perfection all at once! In order to reach perfection one must begin by being ignorant of a great deal. And if we understand things too quickly, perhaps we shan't understand them thoroughly." — Fyodor Dostoyevsky

Tuesday, April 19, 2011

Show me the money

The IMS Institute for Healthcare Informatics recently released its 2010 report on the use of medications in the US (you can view it here). In the list of the top 25 prescribed drugs based on revenue generated, there is only one anti-infective, Atripla, which ranks #23. And you wonder why there are so few new antibiotics in development?

Outbreak at the Playboy Mansion

I'll refer you to Gonzalo Bearman's blog for this one.

MRSA Video - If this doesn't get you excited "almost" nothing will

The video was made by The University Hospital of South Manchester.

Things to note:
1) They start off by washing their hands and not swabbing their noses
2) Ties are tucked, sleeves are rolled up and they're mostly bare below the elbows.

Source: BBC News

Monday, April 18, 2011

Control groups are for losers

That’s what I learned from today’s New York Times editorial. In their review of the two NEJM studies we covered last week (here and here), they describe the VA study as “broader” (true, if by broader they mean larger) and “possibly more rigorous” (untrue). They also point out that “if other hospitals could replicate the effort, thousands of patients might be saved from needless infections”. The editorial board at the NY Times should know that hospitals across the country are already saving thousands as MRSA HAI rates drop nationwide! And many of these hospitals are saving lives without also stimulating the economy by doing universal MRSA screening. A bundle with multiple interventions, one of which is unproven and hugely resource intensive, doesn’t seem in keeping with the spirit of health care reform. And sadly, determining the proper role of the most expensive element in the VA's MRSA bundle requires studies that use something we epidermatologists like to call a “control group”.

Sunday, April 17, 2011

The toilet of your dreams: $6400

The lid opens and closes automatically - hands free. It senses when a guy is standing in front of it and lifts the seat for him. It has auto-flush. It has a cleaning cycle and an "integrated bidet" with a dryer. It has a heated seat and warms your feet.  It even has integrated speakers for your iDevice and a remote control for its many functions. It's pretty ridiculous. I wonder how long it will be until we see it in hospitals?

Engadget April 16th
Gizmodo (with hands-on video)

Saturday, April 16, 2011

Belly Button - Innie? Outie? Petri Dish!

Specimen 1234
Navel, umbilicus, belly button? Some people don't just stare at them. Jiri Hulcr and a team of investigators at NC State have launched the Belly Button Biodiversity project.  The projects seeks to raise awareness around microbiology and show that not all bacteria are harmful. Hulcr also thinks the belly button is an ideal sampling site to investigate the human microbiome. He aims to sequence the 16S ribosomal RNA from each sample.

I know Mike just suggested that all human carnivores be placed in contact precautions, but seeing what grows in belly buttons, I think pretty much everybody should be isolated.  Or perhaps we can just wear little antibacterial N95 masks to cover them up?

NewScientist April 1, 2011
Belly Button Biodiversity Project

h/t Mark Vander Weg

Would you like Staph with that steak?

Photo: Friend of the Farmer
A new study in Clinical Infectious Diseases cultured meats from grocery stores in 5 US cities. Much of it was found to contaminated with Staph. aureus (77% of turkey samples, 42% of pork, 41% of chicken, and 37% of ground beef samples). Moreover, 52% of the isolates were multidrug resistant.

I am now beginning a campaign to have laws passed in all 50 states which will mandate that all human carnivores be immediately placed in contact precautions.

Thursday, April 14, 2011

Set your TIVO: Animal Planet's Killer Outbreaks

A new Animal Planet series called "Killer Outbreaks" starts April 15th.  The 6-episode series features CDC experts and covers Anthrax, E. coli, Hantavirus, Rabies, West Nile, Monkey Pox, Acinetobacter baumannii, Salmonella, Valley Fever, Meningococcal Disease, SARS and MRSA.  It airs each Friday at 10pm ET and 10pm PT. Doesn't get more exciting than that!

CDC Press Release 4/12/2011

Wednesday, April 13, 2011

VA reduces HAIs! In other news, VA spends millions on MRSA screening

Jain and colleagues just published data from the VA healthcare system implementation of the "MRSA directive". For those who are still unaware, in 2007 the VA began mandating the IHI MRSA bundle system-wide, with MRSA screening (active detection and isolation, or "ADI") applied to all VA admissions. The results? From October 2007 until June 2010, the MRSA transmission rate decreased by 17% in ICUs and 21% in non-ICUs, and the incidence of healthcare associated MRSA infections in ICUs fell by 62%. Very impressive indeed.

But that's not the whole story. During the same time period, a subset of these VA hospitals also reported their rates of healthcare-associated VRE and C. difficile infections, and guess what? VRE HAIs fell by 100% in ICUs and 70% in non-ICUs, and C. difficile HAIs fell by 57% in non-ICUs. It seems that HAIs are falling across the VA system, probably as a result of an important culture change, and improved application of so-called "horizontal" approaches to infection prevention. Bravo to the VA!

Here's the problem: because the VA jumped right into universal ADI, utilizing the most expensive screening technology available, they've poured millions of dollars into one specific intervention (ADI), and we still have no idea if ADI had anything to do with their MRSA reductions. After all, MRSA HAI rates have been falling across the country, both inside and outside of ICUs, including in hospitals that do no ADI, or that do targeted ADI. And of course Mike's hospital, where no ADI is done, would scoff at a mere 60% rate of decrease, having reduced MRSA HAIs by almost 90% using horizontal approaches.

My conclusions? First, the VA is to be congratulated for demonstrating real and sustained progress in HAI prevention (disclaimer: I was a VA hospital epidemiologist for 10 years, including during the first 2 years of implementation of the MRSA directive). Second, VA policy makers should consider the possibility that universal MRSA screening is now doing more harm than good, if only because it costs millions of dollars annually that could be used to improve other infection prevention programs. By all means, continue the MRSA initiative. But consider relaxing the "universal" ADI directive to allow individual hospitals the latitude to tailor ADI practices to best address their current risk assessment.

STAR*ICU study published: Barrier precautions not effective

It's only one study. Everybody take a deep breath. OK, exhale.

You might have already heard about this study and you might even know the results.  Someday, someone might discuss how this study was designed, and why the investigators decided to ship all of the microbiology specimens to NIH for processing resulting in a 5-day test turn-around time.  Someday, someone might explain why this study took 4 years to publish and the saga behind its eventual publication in the NEJM.  Someday, someone might even discuss how the difficulties completing this study might be hindering NIAID from funding other infection prevention clinical studies.  Someday, someone.

What can I say about the study?  Barrier precautions (ie. gloves or gowns/gloves) are ineffective in halting the transmission of MRSA and VRE in ICU settings.

Methods: The cluster-randomized trial (ie a largish quasi-experimental study but with a cool fancy name - see my "Random note" below) was completed in 2006 with the intervention lasting 6 months from March to August 2006. There were 10 intervention ICUs and 8 control ICUs.

Random note: There were 18 ICUs in this study, so it's somewhat like an 18-person RCT.  With such small numbers you can't expect that all measured and unmeasured confounders to be randomly distributed between the intervention and control ICUs. Thus, this is more like a large QE study than a standard RCT and needs to be analyzed as a QE study using multivariable regression controlling for known sources of confounding. Don't believe me? Check out Table 2 to see how different the intervention and control arms were in regards to topical and systemic antimicrobial exposure. You would not typically expect these "significant" differences in a large RCT (or large cluster-RCT).

Microbiology: Nasal swabs for MRSA surveillance cultures and stool or perianal swabs for VRE surveillance cultures were obtained from all patients within 2 days after their admission to the ICU, weekly thereafter, and within 2 days before or after their discharge from the ICU. Swabs were shipped overnight, 6 days a week, to the NIH. The mean number of days from obtaining surveillance cultures to reporting of results was 5.2 days.  I would have liked to see this reported in median days and I would also have liked this number to be reported from time of admission and not time from obtaining the culture since 2 days could pass between admission and obtaining the culture.

Planned Intervention: Known colonized or infected patients were placed on contact precautions. All other patients were placed on universal gloving from the time of admission until their discharge or until the results of surveillance cultures results returned. If surveillance cultures were positive, patients were upgraded to contact precautions (gowns/gloves) and if they were negative, they were downgraded to standard precautions.

Actual intervention as implemented: In the intervention ICUs, 92% of the ICU-days were spent under barrier precautions (51% contact precautions and 43% universal gloving) while in the control ICUs, 38% of ICU-days were spent under contact precautions.  Thus, indepedent of what anyone says, this study is about whether increasing barrier precautions from 38% to 92% reduces transmission. Also, 4 times as many patients in the intervention group were exposed to a topical antimicrobial (e.g. mupirocin), 12% vs 3.2%. Now, some will say that there wasn't 100% compliance with these interventions. I agree, this is not an efficacy trial.  As Ebb and I said in our JAMA commentary yesterday, cluster-randomized trials are real-world effectiveness trials in the domain of infection prevention.

Compliance: Overall, 47% of contacts in the intervention arm occurred with clean gloves and exit hand hygiene compliance vs 25% in the control ICUs. Compliance with contact precautions was relatively good in the intervention ICUs: gloves 82% and gowns 77%. Hand-hygiene compliance was also higher in the intervention vs. control ICUs (69% vs 59%)

MRSA or VRE colonization or infection: The mean incidence of MRSA or VRE per 1000 patient days at risk was actually higher in the intervention arm than the control arm (40.4 vs 35.6, p=0.35) but this was not statistically significant.

My thoughts:  How can this study not find a benefit when so many others have? Since most of the previous studies were uncontrolled quasi-experimental studies and we know that uncontrolled QE studies can over-estimate the measure of effect, it is possible that barrier precautions don't work.  It is also possible that other factors need to be included in any MDRO prevention program including attention to environmental cleaning and far higher compliance with the hand hygiene and contact precautions. However, the compliance rates reported in this study are not abnormally low (at least at the mean/median). Finally, perhaps decolonization is needed to achieve the results (at least for MRSA) that we've seen in other studies.

Another criticism that we've heard and will hear again is that the turn-around time for the microbiology was too-long.  This is mostly a red herring.  Since we have little evidence that gowns add much to gloves, and 92% of contacts in the intervention arm occurred with gloves, this study had FAR better glove compliance than we would expect with any typical ADI program in the real world.  The use of universal gloves in the pre-result period in the intervention arm really saved this study and, thus, it provides VERY useful information and should not be discounted. A quicker test turn-around would not have magically led to reduced transmission. Sorry.

Again, this is one study and it shouldn't be the last.  AHRQ is funding some very important MRSA (and VRE) prevention trials that many of us are involved with and I hope the publication of this paper won't discourage AHRQ (or NIH or CDC or VA) from funding these large and important studies.

What this study really tells us is that we can't fall back on legislative mandates in MDRO prevention and we must continue to search for the right combination of interventions along with developing better implementation strategies. Don't stop with the STAR*ICU study. Let this be the beginning.

Huskins W.C. et al. NEJM April 14, 2011

Giving Doctors Orders

Maureen Dowd's column in the New York Times this morning begins as follows:
When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.
Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.
“It could be anything,” he said. “It could be my tie spreading germs.”
I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.
My answers to her question:  (1) ego, (2) dogma.

You can read the rest of her column here.

Tuesday, April 12, 2011

Embracing science, continued...

Also out today, the Department of Health and Human Services announces a new initiative entitled, "Partnership for Patients: Better Care, Lower Costs". From my initial reading, it looks like a 1 billion dollar investment, mostly in implementation of existing prevention approaches.

I'm sure we'll comment further as more details emerge, but I would like to highlight this paragraph from SHEA's statement on this initiative, which appropriately focuses on the need to advance the science of prevention (italics, for emphasis, are mine):

As the Obama Administration moves forward, we urge officials to think beyond the changes that past practice has suggested can make a difference, as well as the financial incentives and disincentives that ostensibly prompt providers to modify how they work. To really be successful, both now and in the long term, the NPSI must invest in the medical research and technology that will identify how the nation’s health system can avoid errors in care. The initiative also must be able to track and validate improvements through standardized measures and solid data. If we focus on implementation without advancing the science, we will fall short of immediate goals and risk being equally unprepared for future exigencies.
Photo credit: Kathleen Sebelius, HHS director, with Elmo. From the NY Daily News.

Addendum: Don't miss Bob Wachter's post on this initiative, here.

Embracing science!

Mike just posted about Peter Pronovost's call for the QI community to "embrace" science rather than to run from it. In this week's JAMA, our friends Eli and Ebb (Lautenbach) have an eloquent description of what it will mean to embrace science in pursuit of more effective infection prevention. Read it!

Monday, April 11, 2011

Denver Health: Rocky Mountain High Quality

The April issue of Health Affairs is a themed issue on Quality. It contains a piece on Denver Health and its focus on quality improvement. I encourage you to read it--you'll note this is an impressive medical center, which is a safety-net, teaching hospital, integrated with the EMS system, outpatient clinics throughout the city, school-based clinics, and the public health department to create a seamless continuum of care. Of note, the observed:expected mortality (0.55) at Denver Health ranks lowest among the 112 academic medical centers in the University HealthSystem Consortium, and despite caring for the medically indigent, the hospital has produced a positive bottom line every year since 1991. Unlike the case at many academic medical centers, the physicians at Denver Health are not provided incentives to perform procedures. All of this speaks to superb leadership. The article also outlines several other markers of high quality, and its CEO and CMO "argue that regulatory bodies should refocus their oversight to consider an institution’s overall structured approach to quality improvement and safety, instead of monitoring individual small outcomes, such as a patient’s receipt of antibiotics for pneumonia within six hours of arriving in the emergency department." Go Denver Health! And a shout out to their hospital epidemiologist, Dr. Connie Price.

Also in the same issue, is a paper on the IHI trigger tool, which I've blogged about before in response to a previous paper in the New England Journal of Medicine. I was going to comment on this new paper as well, but will simply refer you to an excellent posting on this by Bob Wachter on his blog.

Sunday, April 10, 2011

Anti-MRSA N95 mask?

I don't get this.  FDA has just approved an antibacterial N95 mask. The SpectraShield mask is labeled as an N95 surgical respirator with activity against S. pyogenes, MRSA, and H. influenzae when the bacteria are exposed to the outer surface of the mask.  When should these be used and why?  Is there evidence that in settings where an N95 should be used (i.e. caring for TB+ patients) that healthcare workers are contracting MRSA or Group A Strep? Are surgeons acquiring MRSA in the OR from their patients?  I probably missed the publications where they compared HCW acquisition rates between standard N95 and antibacterial N95. Please forward them along. 

PR Newswire, April 8, 2011

Saturday, April 9, 2011

Healthcare quality: Running from science

We've blogged before about our hang-ups with QI. So I was pleased to see a thoughtful perspective in this month's Health Affairs by Peter Pronovost and Richard Lilford entitled "A Road Map for Improving the Performance of Performance Measures." As you might guess, this piece focuses on the validity of quality metrics, and Pronovost deserves credit for trying to push the hospital quality community to clean up its act.

The conclusion of the essay is also the money quote: "For the past decade, health care quality has largely sought quick fixes and run from science; the results are evident. Let us hope that efforts in the next decade embrace science instead."

Friday, April 8, 2011

Staring into the abyss: MDR-GNR edition

We’ve been following the emergence and global spread of the New Dehli metallo-beta-lactamase (NDM-1). The latest chapter of that story came out today in Lancet Infectious Diseases, in a fine example of the newly named field of pharmacoecomicrobiology (say that three times fast!). Tim Walsh and colleagues sampled tap water and wastewater from the epicenter (New Dehli) and from Cardiff, UK. They found NDM-1 positive bacteria in 4% of drinking water samples and 30% of wastewater samples in New Delhi, but none in Cardiff. More alarmingly, they found this highly mobile resistance gene in a wide array of pathogenic bacteria. In addition to the Enterobacteriaceae (in which it has already been described), they found stable carriage of NDM-1 encoding plasmids in Aeromonas, Shigella and Vibrio cholera. Susceptibility testing confirmed phenotypic expression, revealing resistance to broad spectrum cephalosporins and carbapenems. On one hand, this is quite predictable (and furthermore, we know that even short-term visitors to an area of endemic resistance for gut bacteria will carry that resistant flora back home). On the other hand, it speaks to the inevitability of our new post-antibiotic era. This era has already begun, and will proceed incrementally as we see the steady loss of antibiotic classes we once referred to as “last-resort”.

Joint Commission and Influenza Vaccination: IC.02.04.01

This seal in no way suggests that the
Joint Commission approves of this blog
The Joint Commission has just released proposed requirements addressing influenza vaccination of staff and licensed independent practitioners. Revisions to current requirements are proposed for Hospital, Critical Access Hospital, and Long Term Care accreditation programs with new requirements proposed for Ambulatory Care, Behavioral Health Care, Home Care, Laboratory, Medicare Based Long Term Care, and Office-Based Surgery accreditation programs.  Comments will be gathered until May 17, 2011.

You can review the proposed standards and leave comments on the JC site here.

For the Hospital Accreditation Program IC.02.04.01, elements 1-3 remain the same, elements 4 and 5 have been revised and elements 6-9 have been added. The new text is bolded below and the revised elements are:

1. The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff
2. The hospital educates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. (See also HR.01.04.01, EP 4)
3. The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff.

4. The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination.
4. The hospital includes in its infection control plan the goal of improving influenza vaccination rates. (For more information, refer to Standard IC.01.04.01)

5. The hospital takes steps to increase influenza vaccination rates.
5. The hospital sets incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020.

6. The hospital develops a written description of the methodology used to determine influenza vaccination rates. All hospital staff and licensed independent practitioners are to be included in the methodology for determining the influenza vaccination rates. (See also IC.02.04.01, EP 1)
7. The hospital evaluates the reasons given by staff and licensed independent practitioners for declining the influenza vaccination at least annually.
8. The hospital improves its vaccination rates according to its established goals and at least annually. (For more information, refer to Standards PI.02.01.01 and PI.03.01.01)
9. The hospital provides influenza vaccination rate data to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other staff at least annually.

Thursday, April 7, 2011

Copper kills MRSA

VDB's design now only 2.5% Copper
Dr. Bill Keevil of the University of Southampton was just interviewed by the New Scientist. In the article and accompanying video, he demonstrated the MRSA-killing ability of copper. In the study, his group coated copper or stainless steel plates with 107 MRSA. The copper-coated plates began to kill off the MRSA in minutes.  One caveat is that the study seems to have been supported by the Copper Development Agency. Oh, wouldn't it be great if copper killed MSSA and other bacteria too?

New Scientist, April 5, 2011
Weaver et al. Journal of Applied Microbiology, Dec 2010

MMWR - Field notes from the Minnesota measles outbreak

Dan posted last week on the ongoing measles outbreak in Minnesota and he provided many links to useful resources.  Today the MMWR published a "Notes from the Field" that summarizes the 13 epidemiologically linked cases that have been identified as of April 1.  Five children were too young to receive the MMR. 

Banning hands-free faucets: Is Hopkins throwing the bathwater out with the bathwater?

I hope everyone enjoyed SHEA.  Overall, a good meeting with good weather and good science.  I pinch-hit as a moderator for a hand-hygiene session on Saturday.  The original moderator (i.e. Mike Edmond, have you heard of him??) was scheduled to moderate two sessions at the same time and for some reason wasn't able to pull it off.  ;)

There were interesting studies presented in the session including an abstract highlighting iScrub, which Dan has mentioned before.  One particular abstract garnered a lot of press attention - I'm not used to hearing about data in the morning newspaper before the abstract is presented, for example. The study was conducted by Emily Snydor, Lisa Maragakis and colleagues at Johns Hopkins Hospital and aimed to determine the safety of touchless water faucets in their hospital.  They compared 20 newly installed automatic faucets with 20 old standard faucets and found that 50% of the automatic faucets had 15% of standard faucets were contaminated with Legionella. After chlorine dioxide, 29% of the automatic faucets and 7% of standard faucets were still contaminated with Legionella.  Hopkins is now removing all of the automatic faucets from their facility.

Some thoughts: 1) It appears that Legionella is a problem in their system and the automatic faucets are only part of the problem.  Removing them isn't enough.  2) The faucets in the study were not installed at the same time since the automatic faucets were new and the standard faucets were likely years old - could biofilm play a role here?  3) Not all automatic faucets would be the same, perhaps different designs would have different risks.  4) What about other pathogens?  How do you balance lower risk of C. diff or acinetobacter with touchless faucets compared to Legionella?  5) Could the faucets be "reprogrammed" or designed to allow flow of the stagnant water prior to contact with the HCW hands?  This might reduce one benefit of these automatic faucets since they do save a lot of water.

What do you guys think? Is this enough data to ban automatic faucets in hospitals? My other concern is that this study will be misinterpreted and people will become afraid of automatic faucets in places such as airports.  I doubt the Legionella risk in airports outweighs the influenza risk, for example.

NBC - Dallas article, March 31, 2011
VOA article, April 5, 2011

Tuesday, April 5, 2011

The definitive hand hygiene video!

Tired of explaining (and re-explaining) the importance of hand hygiene? Fatigued from answering questions about various aspects of hand hygiene, such as what to say about jewelry and fingernails, or fire hazards?

Then let the New England Journal of Medicine explain it for you! Didier Pittet and colleagues have put together an instructional video on hand hygiene--many of you have probably seen it already, but if you haven't, take a look.

One concern is whether anyone will have the stamina to stick with the video for the full 15 minutes, but the player allows you to click around to a topic of interest if your attention begins to wane. Also, it might have been more effective with a human voice (if it is a human voice, my sincere apologies to that person--but it sounds robotic or synthetic). On second thought, robots may be just what we need on the units: robotic hand hygiene observers who confront healthcare workers on their way out of the room with a detailed assessment of their HH performance!

Friday, April 1, 2011

The spread of "superbugs"

It's as if the Economist knew that SHEA was in session. They just published a briefing on the many reasons behind the spread of resistant bacteria. My favorite quote from the article is that "much of modern surgery relies on the risk of infection remaining low. At the moment, it is close to zero. If resistant strains raise it to even 5%, let alone 10%, a lot of orthopaedic surgery, cataract replacements and other discretionary but life-enhancing procedures would simply stop. That would not be the end of the world, but it would be a step backwards."