Wednesday, June 29, 2011

Infection Control Journals - Hooray!!!

Hanging out at the 1st ICPIC, yesterday.  Pretty exciting with ~1100 attendees from the whole world. Save the date for the next conference in Geneva - June 25-28, 2013.

While wandering about, I got a cool text message from Preeti Malani, an Associate Editor at ICHE, who informed me that the ICHE journal impact score is up to 3.751 - that's quite a huge jump in 1 year.  I suspect it will be even higher next year given the size of the 1-year jump.  Independent of how you feel about impact scores, it is still very good news for those of us that publish in this excellent and well-focused journal.  Given that promotion and tenure of medical school faculty often depend on publication in high impact journals, this is a big deal for academic types. Three cheers to the entire ICHE editorial board and especially Suzanne Bradley, whose tireless efforts should now be fully appreciated.

...and to emphasize that you can never rest on your laurels...Andreas Voss, the ICPIC co-chair, just announced a new BMC journal titled - Antimicrobial Resistance and Infection Control (ARIC).  The website for submissions is not yet active, but I will post the info when it becomes available.

Monday, June 27, 2011

World MRSA Day: troisième partie

The Third Annual, World MRSA Day kicks off in Chicago again this year.  I have pasted the speakers and awardee lists below for your enjoyment. The event kicks off on October 1, but the actual day is October 2, 2011.  It seems like this should be held next year in a place other than Chicago. Perhaps the Netherlands? I heard they had low MRSA rates.
Keynote Speaker is Dr. William R. Jarvis of Jason & Jarvis Associates LLC, a world-renowned MRSA expert and formerly with the CDC. Rob Stafford, anchor of the NBC Chicago evening news and contributing correspondent for NBC Dateline is the emcee. Dr. Jorge Parada, Associate Professor of Medicine and Infectious Disease Specialist at Loyola University Health System also will be presenting and MRSA survivors and their family members will speak and share their personal stories.
2011 awards: Barry M. Farr M.D., Emeritus of UVA is recipient of the "Humanitarian Award" for his outstanding work, dedication and service to raising awareness and preventing MRSA infections. "Man of the Year" award recipient is Loren G. Miller, M.D. M.P.H., Associate Professor of Medicine at David Geffen School of Medicine and investigator of CA-MRSA treatment and prevention at the Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center and 'Woman of the Year' is Illinois State Representative Patti Bellock. The "Public Service" award is presented to the Veterans Administration Health System for their exemplary dedication to patient safety in preventing MRSA infections. Loyola University Health System will receive the "Hospital Leader Award" for their dedication in reducing MRSA infections using ADI.

Saturday, June 25, 2011

New use for BCG vaccine?

Photo: Kirk McCoy, LA Times
The Los Angeles is reporting on a paper to be presented at the American Diabetes Association meeting which shows that BCG vaccine may be helpful in the treatment of type 1 diabetes via its ability to increase TNF, which in turns blocks destruction of insulin secreting cells in the pancreas. This is interesting and may have implications for infectious disease specialists if this therapy is adopted.

Friday, June 24, 2011

Early summer slow down

For various reasons, I suspect we'll be posting less frequently over the next two or three weeks. I know I will, anyway, and I think Eli will also be otherwise occupied. Unfortunately, this isn't because any of us will be lounging in hammocks. The photo is just, you know, a metaphor for less blogging activity. Or maybe it's just a pretty picture.

Thursday, June 23, 2011

Nosing around for staphylococci

In my last post about the newly described MRSA strains that carry the mecALGA251, I referred again to the “empty cassette variants” (or “mecA dropouts”) that are missed by commercial MRSA PCR tests that target the orfX gene but don’t contain mecA primers. I also mentioned that we’d soon be publishing our first year of experience with this. Well, here is the short report I was talking about, describing our ~8% rate of false positivity due to empty cassette variants, and characterizing the strains in question. We found substantial genetic diversity among the “drop-out” strains, meaning that the problem wasn’t due to the introduction of a single clone. When we tested these MSSA isolates using the newer GeneXpert MRSA/SA Nasal Assay (the “Nasal Complete” assay), they were correctly identified as S. aureus but not MRSA (this new assay has primers for the mecA gene). Even the “Nasal Complete” assay is susceptible to false positives, though, from the simultaneous presence of an MSSA and a methicillin-resistant coagulase-negative staphylococcus (MR-CoNS) in the same nose (the prevalence of MR-CoNS + MSSA co-colonization was 3.4% in one study). Indeed, the package insert describes a PPV of about 75% for the Nasal Complete—for MRSA, the 25% “false positives” divide equally between those for which culture was negative (which might reflect increased sensitivity of PCR) and those for which the culture grew only MSSA (which may reflect MR-CoNS/MSSA co-colonization). Who knew the nares would be such a vexing place for those who design and market PCR tests?

Sunday, June 19, 2011

“Not your father’s CMS”

I just returned from my first HICPAC meeting….and no, I won’t risk being thrown off the committee for discussing all of our deliberations on this blog (at least right now I won’t). However, I did want to point out a fun moment from a presentation by John O’Brien from CMS. John gave an update on the CMS Partnership for Patients, which we blogged about earlier.

The PFP is still nascent, and we’ll see how much of an impact it has on the ground. But the presentations by Joe McCannon at SHEA and this one from John O’Brien were both encouraging, and almost certainly reflect the impact that Don Berwick has had on the culture there. The photo above was taken at the break after John’s lecture. As you can see, there is a painting on the back of his suit jacket, depicting patient safety themes. During his talk he briefly discussed this “walking art”, and how it helps start conversations in airports, at conferences, etc. The painting is the work of Regina Holliday, a Washington DC-based patient rights arts advocate. The full story and explanation of the images on the jacket can be found on her blog, here.

Saturday, June 18, 2011

Government funds $4.5 million antibacterial resistance grant: The RUSSIAN government

Dr. Kabanov
I was checking out Missouri River flood reporting in regional papers, when I came across this article in the Omaha World-Herald. It seems that the Russian government is concerned about drug-resistant bacteria and has given a $4.5 million grant to support the work of University of Nebraska Medical Center researcher Alexander Kabanov.  Kabanov leads the UNMC Center for Drug Delivery and Nanomedicine.  I often mention that there is little support for antibacterial resistance research and antibacterial drug discovery. While this is certainly true in the US, we don't have much data on funding in other countries.  Every little (or big) bit helps.

Wednesday, June 15, 2011

Now this takes balls...

In this video a British surgeon barges into a room where the Prime Minister is talking with a patient and kicks out the cameraman because he's not bare below the elbows. Interestingly. the Prime Minister is bare below the elbows and tieless. You can read about the scandalous surgeon here.

Tuesday, June 14, 2011

Surveillance bias and public reporting

This week’s JAMA has a commentary from Haut and Pronovost that’s worth a read, on the topic of surveillance bias. This is Epidemiology 101 for those of us who live and breathe surveillance and prevention, but unfortunately it is not very well understood by patients and public policy makers. So when data like this garbage dump from Consumers Reports are released and generate media attention, more harm than good result. Good hospitals are unfairly maligned, and undoubtedly some hospitals that game their rates or just perform poor surveillance are rewarded. Call me a stupid consumer, but if I require ICU care and have to choose between Vanderbilt, Virginia Commonwealth, University of Maryland and one of these hospitals, I’m choosing one of the first three. Now I'm sure this list includes excellent hospitals, but I have no (zero) confidence in the data presented (i.e. I'm 'getting to zero' confidence).
We’ve blogged plenty about the challenges of public reporting and establishing a level playing field, so I’ll refer readers to these prior posts. As Haut and Pronovost point out, to ignore standardized, accurate and fair measurement (to include external validation) is both “reckless and unjust”. It is also true that “to be done appropriately, quality measurement is expensive”. Cheap shortcuts, like using ICD-9 coding data, simply prove the maxim that ‘you get what you pay for’.

Monday, June 13, 2011

NDM-1 in a US Military Hospital

source: wikipedia
Maryn McKenna has an interesting take on the MMWR report of NDM-1 in a US military hospital in Afghanistan. The patient had NDM-1 containing Providencia stuartii in a blood isolate collected early in 2011. This is the first case of NDM-1 in P. stuartii and in a US military hospital.  The parallels she draws to previous Acinetobacter infections in military hospitals are interesting. However, I'm not sure you can compare a specific species (Acinetobacter) to a plasmid-borne metallo-ß-lactamase (NDM-1), which can hop from species to species.

Either way, we will eventually need to beef up surveillance, infection prevention research and antibacterial drug discovery.  GNRs are not going away. I suspect the worldwide response to the many MDR-bacterial threats is going to require a significant reorganization and renewed focus (e.g. 1940s and 1950s) on how we fund these efforts. The days of nickel and diming these efforts, are coming to a close...

Wednesday, June 8, 2011

I need your vote!

Last week I posted an idea on the 2011 VHA Employee Innovation Website.  Now VA employees are being asked to vote.  The instructions say that I should share my idea with my colleagues - that would be you. If you work for the VA and like my idea, please vote! Hvala lijepa.

Idea Title: Driving Patient Safety with Point-of-Use Signs for Hand Washing

Idea Description: One of the biggest threats to patient safety is hospital-acquired infections. Hand hygiene is the #1 method for preventing the spread of infections. VA has done a great job placing alcohol hand rub dispensers in patient care areas, but hand washing isn't 100%. Placing point-of-use reminder signs directly next to hand-rub/soap dispensers to encourage providers to wash their hands has potential to significantly improve hand washing compliance. Signs that offer encouragement and information and not just say employees must wash hands would be simple to design, test, implement and be very cost-effective.

Vote: Here

Always playing catch-up

Reports of the emergence of novel MRSA strains bearing mecALGA251, discussed in Eli’s excellent post, were published just as I finished a pro-con session at ASM on the use of culture versus PCR for clinical detection of MRSA. I pointed to the ongoing evolution of MRSA as a drawback to existing PCR methods, and included reference to the "empty cassette variants" that I previously discussed.

Because I think the "empty cassette" or "mecA dropout" story is instructive here. When the orfX-based assays were initially released, the published data described a very low incidence of these variants (in the case of the "mecA dropouts", isolates of MSSA that tested positive by the GeneOhm-GeneXpert-BD test...the opposite problem we see with the mecALGA251 isolates, which are MRSA that test negative....). So the potential problem was minimized, mainly for lack of good data and an assumption that clinical labs wouldn't run across these strains very often. Of course, some labs (including ours) did run across them quite often (“empty cassette variants” constitute almost 8% of our positive tests, a finding we'll soon publish (manuscript "in press" at JCM)).

Similarly, we are going to hear about how rare these mecALGA251 isolates are, how clinical labs are not likely to run across them, the tests still perform well, etc., etc. But how will we know when we start running across them? Of the hundreds of labs doing MRSA nares screening by PCR, how many are doing culture in parallel (not just on positives, but on negatives as well)? Of the labs that do only culture, how many are also doing confirmatory mecA PCR and following up on any phenotypic MRSA that test PCR negative?

More to come on this topic, and what is says about the future of PCR testing for MDRO detection, in future posts...

Tuesday, June 7, 2011

Super Sneaky MRSA (but only if you use PCR)

Lost in the din of our Rice Crispies or even the E. Coli outbreak in Europe, are a couple papers out of UK/Denmark and Ireland reporting novel mecA containing MRSA in human and bovine populations.  The concern here, of course, is that in many centers these novel MRSA strains would be missed by static PCR tests, which is what actually happened in these reports. 

The report out of Ireland discusses two clinical MRSA isolates that were PBP2a-positive but mecA negative by conventional mecA PCR - ie they were called MSSA by GeneXpert. The first strain was isolated from a 64-year old in a Dublin acute care hospital, while the second was isolated from an 85 year-old in a South-East Ireland regional hospital. Evaluation determined that these strains contained a novel SCCmec element (Similar to SCCmec XI) with divergent mecA, mecI, mecRI, blaZ and ccr genes.

In the second report, investigators out of England noticed bovine MRSA strains which tested negative after standard PCR tests for mecA. They determined that they contained a novel mecA homologue, mecALGA251. They then searched collections in Scotland, England and Denmark for similar strains and 51 human isolates with the same mecALGA251. 14 of 25 from London, 12 of 16 from Glasgow and 24 of 32 clinical strains from Copenhagen contained the novel mecA. One human strain dated back to 1975, although detection increased substantially between 2007 and 2010. 54% (13/24) of the bovine isolates were also positive. The distribution of cattle and human isolates in England is shown above.

The authors of this paper suggest that new PCR primers will solve the problem. It is true that it will solve this particular problem, but is it a good long term solution?  Do we think MRSA evolution will stop here? Also, they suggest that dairy cows could be a reservoir of infection, but I would think that humans could also be the reservoir.

What this suggests to me is that if you isolate/decolonize patients using a static PCR for mecA, it is not surprising to me that other novel strains could emerge.  Hand hygiene would not be so easily circumvented, nor would simpler culture-based microbiology methods.

Hopefully our resident microbiologist Dan will chime in too...

UK and Denmark report: Garcia-Alvarez et al. Lancet ID June 3, 2011

Ireland report: Shore AC et al. AAC, June 2, 2011

Tara Smith's take can be found here and Scientific American's report by Katherine Harmon here

The E. coli outbreak according to Kent

Here's a link to Kent Sepkowitz's take on the German E. coli outbreak in Slate Magazine. No mincing of words here. The title sums it all up: We eat crap. It makes us sick. 

Monday, June 6, 2011

One more time: If you're sick, stay home!

In the June issue of Infection Control and Hospital Epidemiology there's a report on an outbreak of H1N1 influenza among healthcare workers in a Chicago hospital in May 2009. This was prior to the availability of the vaccine for this influenza strain. It should come as no surprise that 55% of the HCWs who developed swine flu worked for at least one day while symptomatic. Another example of presenteeism.

On a more positive note, the Connecticut legislature has passed a bill that mandates sick pay, which should help to reduce presenteeism, though lack of sick pay was likely not the problem at the Chicago hospital. Nonetheless, I don't think that most hospitals are making a sincere effort to keep sick workers at home.

Sunday, June 5, 2011

Were bean sprouts the vehicle for E. coli O104:H4?

Some new developments today in the enormous enterohemorrhagic E. coli (EHEC) outbreak in Germany, an outbreak that has sickened at least 1600, caused over 600 cases of hemolytic uremic syndrome (HUS), and killed 22 so far. Daily updates can be found at the European CDC site, here.

Eli has blogged several times about the FDA Food Safety Modernization Act, which was passed several months ago. That law will do little to protect U.S. consumers from foodborne illness, however, if the FDA is not provided sufficient funding to implement it. Perhaps they should serve a delicious bean sprout salad at the next House Appropriations subcommittee meeting--we'll find out if our representatives are confident enough in U.S. food safety systems to eat it.

Friday, June 3, 2011

Surgeons Talking Found Unhealthy (STFU)

There’s an interesting (but very small) pilot study in the British Journal of Surgery that examines the relationship between operating room noise and surgical site infection (SSI) rates. A Swiss group--which previously correlated a subjective perception of increased noise with SSI--measured sound levels in 35 ORs during elective abdominal operations. Median sound levels were significantly higher during cases of patients who subsequently developed SSI (43.5 dB vs. 25.0 dB, p=0.04). Also of note: talking about non-surgery-related topics was associated with higher sound levels, and sound levels increased about 60 minutes after incision. Since we already know that SSI risk increases with the duration of a procedure, it may be that longer surgeries are also associated with more, and louder, non-surgical conversations as the team becomes bored or distracted (though not statistically significant, the procedure duration was longer for SSI patients in this study (mean of 390 vs. 255 minutes)). And as the authors note, higher sound levels could simply reflect the difficulty of a procedure (suction machines, alarms, louder and longer conversations, primal screams, etc.). Future studies could help determine if higher OR sound levels are just markers for difficult, stressful cases, or if more noise negatively affects surgeon performance (or both!).

Thursday, June 2, 2011

Germophobia meets capitalism

Photo: New York Times
This morning's New York Times has a piece by Farhad Manjoo, a technology guru, on devices designed to kill germs. These include gadgets to sanitize your cellphone, toothbrush, floors and your kitchen cutting board. Some advice: there are many better ways to spend your money.

Wednesday, June 1, 2011

Another worry for the hospital epidemiologist (part 2)

Photo: Jeff Swensen, New York Times
We've blogged before about LTACHs (long-term acute care hospitals) and the role they play in amplifying and disseminating multi-drug resistant pathogens. A recent report in Clinical Infectious Diseases describes an LTACH outbreak of group A streptococcus, which is arguably one of the most antibiotic susceptible (though highly virulent) pathogens. In this 57-bed facility there were 11 cases, 8 of which were bacteremic, and of which 2 died. The outbreak continued for 4 months. The report notes poor infection control practices and a delayed recognition of an outbreak by infection prevention personnel in the facility. The editorial accompanying the paper is also worth reading. Given what we know about LTACHs and their patient population, it may be wise for acute care hospitals who receive transfers from LTACHs to initiate empiric contact precautions for these patients until the patients can be fully evaluated (and those of you who know my feelings about contact precautions know that I almost never argue in support of contact precautions).

Should you shake your patient's hand? Not if she owns a cellphone!

A recent AJIC article is getting a lot of press attention. Investigators cultured the cellphones (mobile phones) of patients, visitors and health care workers for hospital pathogens.  The study out of Medicine Inonu University in Malatya, Turkey reported that 40% of patients' phones were contaminated with pathogens while fewer HCW's phones were contaminated (20%). Patients' phones were more likely to be contaminated with MDR-bacteria including MRSA, ESBLs, and carabepenem-resistant Acinetobacter.  Yikes!  And I only thought cellphones caused brain cancer. A bad week to be a cellphone, for sure.

Tekerekoglu, et al. AJIC June 2011