Monday, May 30, 2011

The surgical mask for the non-surgeon

Photo: LesterHo
My favorite section of GQ magazine is the column, The Style Guy, in which Glenn O'Brien solves sartorial conundrums. The June issue has a question from a reader asking whether it's ok to wear a surgical mask with a suit when you're recovering from the flu and want to get back to work. Here's his response:
In Japan the surgical mask is more normal than a hat. Ths is sometimes because of Japanese courtesy, keeping their germs to themselves; sometimes because of their fear of germs; and sometimes in homage to Michael Jackson. In America you can't pull the mask off with anything but scrubs. My position is, if you're sick enough to be contagious, stay the hell home.
There you have it. Even the Style Guy is down on presenteeism.

Rethinking the System: Atul Gawande's HMS commencement address

JR Hildebrand and his pit crew
"A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care...We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions."

You can read the full speech in the New Yorker (here)

Saturday, May 28, 2011

New C. difficile drug approved

Fidaxomicin, the new drug we discussed here, was just approved by the FDA for treatment of Clostridium difficile disease. Price is still not available, but I agree that it is likely to cost at least as much as brand-name oral vancomycin (the parenteral formulation of vancomycin can be formulated for oral use much more cheaply, a practice that is now common). If it is that expensive, fidaxomicin probably will be reserved for recurrent disease (the clinical trial demonstrated equivalence for treatment response, the benefit of fidaxomicin was in reduced recurrence rates among patients with non-NAP1/BI strains).

Photo: Dr. Sherwood Gorbach, Chief Scientific Officer at Optimer Pharmaceuticals. Sandy Huffaker/New York Times

Wednesday, May 25, 2011

Twisted logic

Graphic: WeirdSpace

There's a piece in this week's American Medical News on the New York bill to mandate bare below the elbows. It includes this quote from Dr. P.J. Brennan, former President of SHEA:
It's not as though, by eliminating sleeves, you eliminate germs. The key thing to understand is that these environments are not sterile and are never going to be sterile. That goal is unattainable in a clinical setting. The real goal is to adhere to good hand hygiene, isolation practices, gloving, barrier precautions -- that's where we'd put our money.
I think Dr. Brennan's argument represents the conventional wisdom among hospital epidemiologists, but it doesn't make sense to me. He supports contact precautions, but doesn't support bare below the elbows, both of which are based on the same evidence and assumptions. So I think his logic is twisted. It seems to me that you either believe that clothing has the potential to transmit pathogens or you don't.

Tuesday, May 24, 2011

Is a graduation handshake a risk factor for bacterial pathogens?

University of Maryland dean, Dr. E. Albert Reece,
shakes hands during a graduation
In all likelihood, many of us have just suffered through enjoyed sitting through a recent preschool, high school, college or medical school graduation. The astute readers of this blog probably noticed the alcohol hand rub dispensers on stage for use by the graduates prior to shaking their dean's hand. You also noticed how few graduates actually used the dispensers.  Maybe they were nervous or rushed or were already wearing gloves to go with their graduation contact precautions.

So, should a dean worry about catching bad bugs from their students?  According to a new study published in the Journal of School Nursing, there is very little risk of acquiring a bacterial pathogen during a brief hand shake. In the study, cultures were collected from school officials' hands before and immediately following graduation. From a sample of 5,209 hands, Staphylococcus aureus was separately detected on one pregraduation right hand, one postgraduation right hand (different strain), and one postgraduation left hand, while nonpathogenic bacteria were found on 93% of the hands. They estimate the acquisition risk as 0.019 pathogens acquired per handshake. Of course, the study didn't test for viral transmission, which to me is a bigger worry.

New York Times LA Times May 23, 2011 (Dr. Reece from U. Maryland School of Medicine is quoted in this article)

Saturday, May 21, 2011

Off to ASM

I'm off to New Orleans today, to attend the ASM General Meeting. I'm scheduled to give a talk Monday morning as part of a "pro-con" session on rapid diagnostic testing. Even though the world might end today, I prepared a talk in advance. My task is to argue that culture is just as good (or in some ways even better) than rapid PCR-based techniques for MRSA screening. Fun! Next week I'm giving another talk at our local library. I'll be explaining why a typewriter is just as good as a computer if you're writing something that is expected to have little impact.

Thursday, May 19, 2011

CDC finally addresses zombie threat

The CDC is getting a lot of media attention for finally turning their attention to zombie preparedness. As regular readers of this blog know, we called for decisive action (and the development of a rapid screening test) almost two years ago. I’m not sure what took the CDC so long to address this threat head-on. Rest assured, dear readers, that we’ll stay on the zombie beat and alert you immediately to their emergence. Our goal? Zero zombies.

Cute story of the day

At lunch today, one of my anthropologist colleagues was telling the story of her kindergarten-age daughter and her daughter's friend.  They were discussing hand washing and the children said, "You know, it is much quicker to wash your hands if you don't use soap."  It's impressive that a 5-year old could be an efficiency expert.  What is sad is that many clinicians use the same logic in hospitals when they are 45 or 55 years old.

Tuesday, May 17, 2011

One-Two-Many: A new way to count HAIs?

I’m reading a fascinating book by Daniel Everett, entitled, “Don’t Sleep, There are Snakes: Life and Language in the Amazonian Jungle”. I’m no linguist, but I enjoy his observations about how the development of language is informed by the needs of the culture—based upon his time living and working with the Pirahã people in the Amazon. One of his observations, also described by his colleague Peter Gordon in this Science article, has to do with the way the Pirahã “count” (or describe an amount) by using a “one-two-many” system. How is this relevant to hospital infection prevention, you ask? Well, as we adopt a new goal of zero HAIs, and as infection rates (and denominators) become much less important than whether an infection occurred or not, I wonder if we should simplify our surveillance by using a “zero-one-two-many” system to count HAIs….it sure would save a lot of time.

Monday, May 16, 2011

The decline effect

Graphic: The Ebb & Flow
I had a driveway moment yesterday. On the way home from the gym I turned on NPR and got sucked into this segment on the decline effect, the tendency for experiments when repeated to yield less impressive results. And this phenomenon is apparently only partially accounted for by regression to the mean. You can listen to the segment here or read an article on the decline effect in the New Yorker here.

Thursday, May 12, 2011

Bedbugs and superbugs and bears, oh my!

Combine superbugs and bedbugs and what do you get? At least one publication, and a lot of media attention, that’s what. I was trying my hardest to ignore this story, but our stat counter shows that we now have a sizable readership—how can I let them down? My solution to this problem: we should try to destroy bedbugs wherever we find them (oh, we’re already doing that? OK). As for the over 4 million people in the U.S. who carry MRSA in their noses, let's let them live.

Wednesday, May 11, 2011

Using viruses to detect bacteria!

The FDA just approved a new rapid detection test for MRSA and MSSA from blood cultures that are positive for Gram positive cocci (GPC). The most widely used tests for rapid MRSA or Staphylococcus aureus detection from blood cultures are real-time PCR tests by BD and Cepheid. These tests are limited by both cost and by some performance issues, one of which I referred to here.

The interesting thing about the new Microphage test is that it utilizes bacteriophages specific for S. aureus. The advantage of the test is that it is a simple immunoassay, requiring no special equipment or platform—the immunoassay detects phage antigens, which accumulate only if their target (S. aureus) is present. The MRSA/MSSA distinction is made in a similar manner, but using cefoxitin to inhibit the MSSA that the phages would otherwise feast upon. From the data in the package insert and in this ICAAC abstract from last year, the main limitation is a sensitivity of 91.8% for detection of S. aureus. If the result is positive for S. aureus, the assay is very accurate for distinguishing MRSA from MSSA (accurate enough to meet FDA standards for any commercial susceptibility test). So positive results should be useful, while negative results may not be (negative predictive value will vary based upon the proportion of all blood cultures positive for GPC that are S. aureus).

I could find no peer-reviewed literature on this test (point me to it if you can find anything), so we’ll have to see if real-life performance matches the trial data presented in the package insert. Cost will also be a big issue, and my understanding is that they haven’t settled on a price at this point.

Regardless of how it pans out, you have to love the concept of using bacteriophages for diagnostic purposes…compared with our nucleic acid detection tests, proteomics, etc., it just seems so…..old school!

Cholera update

As the cholera outbreak in Haiti continues, it seems likely that the disease will become endemic there. This tragedy for the Haitian people has regional implications as well, with potential for rapid spread to neighboring countries. There are two recent notable papers in Annals of Internal Medicine, one modeling the outbreak and one editorial about the complex prevention challenges there. Safe potable water, sanitation, and vaccine delivery for prevention; rehydration and antibiotic therapy for treatment--all require infrastructure that doesn’t yet exist in Haiti.

Sunday, May 8, 2011

Changing the equation?

Remember Eli’s post from last month, about a tipping point at which the risk for a multiply-drug resistant infection begins to outweigh the benefit of a “discretionary” surgical procedure? I thought about that when I read this report about MDR-GNR sepsis after prostate biopsy, which may lead to a re-evaluation of PSA screening guidance. Hat tip to Jason Barker for sending me the link. The two money quotes:

“We’re all beginning to see more and more sepsis as a result of resistant bacteria after prostate biopsies,” said Peter T. Scardino, chief of surgery at the Memorial Sloan- Kettering Cancer Center in New York, which does about 2,000 of the tests annually. “This is an extremely worrisome problem”


“There has been this huge enthusiasm for everyone getting their PSA checked, which has led to a lot of prostate biopsies that have not benefited anyone,” said James R. Johnson, an infectious diseases physician at the Veterans Affairs Medical Center in Minneapolis. “The more dangerous the biopsy becomes because of infection risk, the more likely it is that the balance is shifting toward harm, rather than benefit.”

Those deviants!

Photo: OpenIDEO
I have a bookshelf that is filled with many books on leadership and management that I read while working on my Master of Public Administration degree. While each of them might have a kernel or two of unique insights, most of these books contain a great deal of fluff. The basic formula for these books is to take concepts that are often common sense, give them a new name, and create the illusion of a totally new discovery about human behavior.These books often focus on a magic number--7 principles, 10 milestones, 12 steps (wait, that's something else!), and they continue to be steadily churned out (just take a look at any airport bookstore). Of all of these books that I've read, one did stand out as different and important, and that was Robert Greenleaf's Servant Leadership.

One recent book in this genre caught my eye given it's potential application to HAI prevention: The Power of Positive Deviance: How Unlikely Innovators Solve the World's Toughest Problems. Positive deviance was a part of the interventions implemented in the Veteran Affairs initiative to reduce MRSA that was recently reported in the New England Journal of Medicine (see Dan's comments here and here). My colleague in Sao Paulo, Alex Marra, has published on his use of positive deviance to improve compliance with hand hygiene. You can read an interview with Alex focusing on the use of positive deviance here.

In a nutshell, the concept of positive deviance is to simply involve not just experts but everyone in identifying solutions to problems. And it recognizes that a few individuals (the positive deviants) devise solutions to problems that the vast majority of people never realize. The deviants then share their successes with others and in doing so previously intractable problems are solved. Importantly, change is driven bottom-up, not top-down. The book uses several case studies, including the Pittsburgh VA hospital MRSA initiative.

Like the overwhelming majority of leadership/management books, this is another one that essentially follows the same formula as many others--a relatively simple, commonsense concept is given a new name, and presto, problems appear to be solved. I have no doubt that positive deviance can be used successfully in infection prevention, but it's simply another way to achieve the outcomes we want. It's not magic and it's not the be-all, end-all. But it's another tool, and if it works for your organization, well, you go girl!

Thursday, May 5, 2011

Pre-emptive contact precautions of intubated patients: effective??

One of the odd things about contact precautions is that they are typically used to isolate patients colonized or infected with MDROs like MRSA. What this does is protect the healthcare worker from being contaminated with the MDRO but does little to protect the uncolonized patients.  The contact "event" we should MOST care about is contact between the contaminated or colonized healthcare worker and the uncolonized patient. So, current active detection and isolation programs have it all wrong. Please read that paragraph again.

Thus, I read with interest a paper just e-published in the JHI by Matsushima et al.  The authors noticed, using surveillance data, that ventilated patients in their ICU were 8 times as likely to acquire MRSA compared to non-ventilated patients.  Based on this finding they decided to place all ventilated patients on contact precautions throughout their stay to see if it reduced MRSA acquisition.  This intervention is close to a universal contact precautions intervention (or close to the STAR*ICU study that was a study of barrier precautions - gloves or gowns/gloves).

The study was completed in a 19-bed ICU in Osaka, Japan.  A unique (for the US at least) characteristic of this ICU was that only 2 rooms were single-bed rooms while the remaining 17 beds were in a single open ward. There were 2 study periods.  Period 1 occurred during 2004 and period 2 was a 3-year period from 2005-2007. During period 1, contact precautions were only used if the patients was found to be colonized with an MDRO. Surveillance cultures were obtained on all admissions and weekly using sputum, nasal and urine sources. During period 2, the same practices existed as period 1, but all patients who were intubated were placed on contact precautions for their entire stay.  MRSA acquisition occurred when a patient negative for MRSA on admission culture became positive on a subsequent surveillance or clinical culture.  They actually completed segmented Poisson regression looking for changes in slope/intercept of HA-MRSA rates. Woo woo!

The main difference between period 1 and period 2 was that many more people were placed on contact precautions during period 2. In period 1, 2.9% of patients were MRSA+ on admission and isolated while in period 2, 6.1% of patients were MRSA+ on admission, but fully 43% of patients were placed on contact precautions. Importantly, the colonization pressure was 2x greater in period 2.  Keep that in mind...

Interestingly, HA-MRSA infection in all patients declined from 3.6 to 2.3 per 1000 patient-days, p<0.05. The incidence of HA-MRSA in the intubated patients greatly decreased from 12.2% to 1.1%. I have pasted the key figure -->.  What it shows is that while HA-MRSA colonization and infection declined in intubated patients it actually slightly increased in non-intubated patients (who could be considered a non-equivalent control group).  Very cool.

Usual caveats: single center with somewhat unique bed arrangement in the ICU, and of course the control group wasn't random.  However, this is a fairly strong quasi-experimental study with good epi and statistical methods. And it points out that isolating patients actually PROTECTS them, so if there are downsides associated with contact precautions, like fewer visits from healthcare workers, at least the patients isolated directly benefit from the isolation.  This sort of study could actually help flip how we think about contact precautions. Isolate the uncolonized!

Simulating pandemic spread with a phone app?

Source: BBC News
Researchers at the University of Cambridge Computer Laboratory have developed (along with 7 other institutions) the FluPhone app that tracks how people interact and potentially spread influenza or other pathogens.  The app uses Bluetooth technology to anonymously record interactions between volunteers. When cellphones come into close proximity, the interaction is recorded and data is sent to the researchers.

A just-released version of the FluPhone app can transmit fake pathogens to other phones so that the team can randomly "infect" one phone and see how it spreads within the volunteer community. Pretty cool. I wouldn't head to your favorite app store to volunteer just yet, since this study appears confined to the UK and Nokia phones. I actually forgot that Nokia made mobile phones.

Source: BBC News, May 4, 2011

Wednesday, May 4, 2011

Predicting flu in 140 characters or less

Early on in the 2009 H1N1 epidemic, I posted about how some of our Iowa colleagues were tracking public interest in H1N1 (then still called “swine flu”) by tracking tweets in real time. Well, they’ve now published their findings, which are extremely cool, in PLoS ONE.

Following public opinion about an emerging infection is interesting enough, but I especially like their use of Twitter to predict influenza-like illness (ILI) rates. Check out figures 9 and 10 to see how closely Twitter traffic tracked reported ILI cases (once models were developed to determine the relative contributions of each influenza-related Twitter term to predicting ILI rates). As these authors point out, real-time Twitter data precedes traditional surveillance information by a couple weeks, which could be quite useful in public health planning and preparedness.

Check out other cool stuff from the computational epidemiology group at Iowa

Bare below the elbow: New interest in the US?

Graphic: YNN-NY
A group of lawmakers in the New York state senate are considering a legislative mandate for bare below the elbow in New York hospitals, and perhaps even requiring hospitals to supply uniforms or on-site laundry facilities. You can read about it here.

5/8/11 addendum:  Here's an update with more detail.

Dr. David J. Sencer, a “public health giant”

Dr. Sencer was CDC director during smallpox eradication, the swine flu episode, and the discovery of the cause of the respiratory infection outbreak at the American Legion convention in Philadelphia in 1976. He was also the New York City health commissioner during the early years of the HIV epidemic. He died on Monday at age 86. According to Dr. Tom Frieden, he stayed involved at CDC until very recently:

"At the height of the H1N1 pandemic of 2009, he was here full time, and I said, ‘Can I pay you?’ He said, ‘No, this is a labor of love.’"

NY Times obituary
Photo by William E. Sauro, The New York Times

Tuesday, May 3, 2011

Monday, May 2, 2011

When soap goes bad

Photo: Funny Blog
A new paper in the Journal of Applied and Environmental Microbiology (free full text here) describes a trial in which liquid soap was intentionally contaminated in grade school restrooms. The investigators found that when children washed their hands with contaminated soap there was a 26-fold increase in gram-negative rods on the hands. On the other hand, when uncontaminated soap was used there was a 2-fold reduction in hand contamination. It has previously been shown that soap dispensers which require refilling have been linked to outbreaks, and CDC recommends that soap not be added to partially empty dispensers (i.e., topping off). The solution to this problem is to use sealed soap-dispensing systems.