Sunday, July 31, 2011
Hat tip: Rebekah Moehring
Friday, July 29, 2011
Tuesday, July 26, 2011
Now I am not saying this to be flippant or mean, but here's an example of how having the best MRSA control program in the world doesn't protect patients from other important pathogens. It's one of the most compelling arguments for focusing on practices that impact all organisms transmitted via contact--what we call a horizontal approach to infection prevention. Dan Diekema once said (on NPR, no less), "MRSA's not the only bad bug out there. It's just the most famous."
Sunday, July 24, 2011
Using the NHANES dataset, the South Carolina investigators found that persons who drank coffee or hot tea were half as likely to be colonized with MRSA, even when controlling for age, race, socioeconomic status, health status, hospitalization in the last year and antibiotic use in the last month.
Now it's important to remember that this is an observational study, which doesn't allow us to determine causation, as we know that these studies can be plagued by bias and confounding. Nonetheless, the authors do elaborate on the biologic plausibility for their tantalizing finding.
I'm just saying it sure beats squirting mupirocin up your nose!
The behemoth healthcare system, University of Pittsburgh Medical Center, had its living donor transplant program temporarily shut down after a patient was transplanted with a kidney from a hepatitis C infected donor. The details of the fateful transplant can be found in two well-written articles in the Pittsburgh Post-Gazette (here and here). It's a classic example of the swiss cheese model of complex system failure, where all the holes lined up (in this case the positive lab test was missed on 6 occasions), allowing an adverse outcome to occur. The articles note that UPMC's response was to demote the transplant surgeon and suspend the transplant nurse coordinator. A noted transplant surgeon describes that as an administrator's knee jerk reaction and another stated, "if everyone in transplants got hit for making a mistake, no one would be working." But the journalist probes to unearth how the system fostered the error, and he notes the stresses on the surgeon to increase surgical volume (as well as stressors in his personal life), problems with the electronic medical record, and alarm fatigue.
I have been intrigued at how physicians who perform the most highly technical procedures in medicine can sometimes be uninterested in details that ultimately can unravel their programs. What infectious diseases physician hasn't been consulted to see a patient who has undergone an amazingly complex surgical procedure, who survived against all odds only due to an enormously talented surgeon, all to be undone by sloppy infection control practices down the line, such as noncompliance with hand hygiene? In the UPMC case, I have to wonder whether a simple tool, such as a checklist, could have prevented this error.
Friday, July 22, 2011
My favorite quote is from the mother pictured above: "You have a gentle touch sir, I want you to be my baby's namesake. What is your name, sir?" A: "Ignaz"
Another moving section: Semmelweis: "I believe that this practice will save lives." Senior physician: "but this is not our way, at this hospital, doctor, we must be unbending in our practice."
The film is available for viewing on the Sloan Science and Film website (here)
Thursday, July 21, 2011
Page 818, Tohme, Rania A et al. reviewed hepatitis B vaccination rates and immunity among healthcare students during a 10-year period at Emory University. They report that among 4,075 students, only 60% had documented vaccination and 84% had anti-HBs concentration greater than or equal to 10 mIU/mL. It is interesting that despite CDC and ACIP (1995) recommendations of routine vaccination of children aged 11-12 years, and for all less than 18yo in 1999, the majority of students were only recently vaccinated.
If I left you off this list, sorry! You are still awesome!
Wednesday, July 20, 2011
|Feedback loop photo from wired.com|
There is a very interesting piece in last months Wired that discusses the success of just the type of feedback loops that Dan suggested. The initial example they give of a successful feedback loop is those real-time dynamic speed displays, or driver feedback signs, that have a speed limit posting coupled with a huge sign announcing “Your Speed.” In this example, speeds fell 14% and were below the speed limit! I guess you can change behavior.
Could we incorporate such feedback, "as close to the point of care as possible" as Dan suggested, and improve hand hygiene compliance by 14%? Anyway, a very interesting article and they even included a podcast/mp3 that is a good listen.
Source: Thomas Goetz "Harnessing the Power of Feedback Loops" Wired June 2011
Tuesday, July 19, 2011
Monday, July 18, 2011
|VCU Internal Medicine Team 3|
Photo courtesy of John Le, M-4 as of today (far left)
Thursday, July 14, 2011
Oh, by the way, the CDC has just released their new Guide to Infection Prevention for Outpatient Settings.
h/t Jan Kluytmans
Tuesday, July 12, 2011
Talking about bias is so pre-millennial. The kool kids are more interested in metabias. Metabias, by definition, only rears its ugly head when groups of studies are examined. Meta-epidemiological studies (e.g. meta-analyses) can uncover risk factors for bias that don’t seem to be associated with a process active in an individual study. That’s metabias! We’ve blogged about several specific forms of metabias before, including publication bias and citation bias. A new form of metabias is described in this week’s Annals of Internal Medicine: it turns out that single-center trials consistently report larger treatment effects than multicenter trials, even after controlling for sample size and other factors. It’s not clear why this is the case, nor is it possible to determine which study type (single-center or multicenter) gets closer to the “truth” (though I strongly suspect the answer is multicenter). Given that many HAI prevention studies happen to be single center studies, this problem bears further scrutiny…..and a willingness to fund larger (more expensive) multicenter trials.
Monday, July 11, 2011
|Gobo and Wembly Fraggle deliver fluoroquinolones to the wise Trash Heap|
Now we have some more news about fluoroquinolones and again it comes from Cleveland. Nicole Werner and colleagues reviewed six weeks of fluoroquinolones prescriptions at a city-hospital in Cleveland. The study covered 227 courses in 226 patients (why not exclude the single patient treated twice?) and 1,773 total days of therapy. 70 (31%) or the regimens were deemed unnecessary and fully 690 days (39%) were determined to be unnecessary.
Twenty-seven percent of the regimens were associated with adverse effects - GI adverse effects (14% of regimens), colonization by resistant pathogens (8%), and Clostridium difficile infection (4%).
I know, it is probably too late to save fluoroquinolones from the trash heap of used-up antibiotics, but when will we ever learn? Do you think it's time that antimicrobial stewardship programs are finally mandated for all hospitals? I suspect we will probably have to limit antibiotic prescriptions to ID specialists to have much of an effect. Many of us have wondered why only oncologists can prescribe chemotherapy while every clinician can go about prescribing antibiotics willy-nilly. Why do we continue to squander a limited public health resource like antibiotics? It is not like the findings of this new study are all that surprising - I actually thought it might be worse. Yet 40% of fluoroquinolone-days are wasted and 27% of patients get a side-effect with 4% getting C. diff?? Really? That means for every 25 patients treated, one gets C. diff. How bad does it have to get before we change our system of antibiotic prescriptions? EOR
Werner NL et al BMC Infectious Diseases 2011
Sunday, July 10, 2011
Buried in the methodology, the publisher of Consumer Reports agrees that comparisons must be done carefully, but the article does not reflect this caution. Instead, the article draws broad conclusions about the quality and safety of care throughout entire health systems based on one measurement gathered from a single unit in each hospital.While Consumer Reports may know how to evaluate refrigerators, they have a long way to go in order to produce a high quality assessment of health care.
Wednesday, July 6, 2011
Tuesday, July 5, 2011
|At least no funding for ESCKAPE pathogen research|
Last year at IDSA, Roy (Trip) Gulick stated that there are now 10,000 possible ART combinations for HIV treatment. When he said that, I instantly got a sinking feeling in my gut. Right now, there are many people colonized and infected with resistant bacteria for which we have NO EFFECTIVE THERAPY. Sorry for shouting. Think about the MDR-Acinetobacter or NDM-1 strains that are circulating. Pretty soon we won't even have effective therapy for community UTIs.
As I thought about why this might be, I looked for the federal funding picture for antibacterial resistance research, but there were no published data. So, we found the numbers ourselves. I presented the data last week and Marin McKenna kindly described our findings at the World HAI Forum on her Wired Superbug blog. She did a much better job describing our research findings than I could have. If you're interested in reading about how much NIH/NIAID spends on antibacterial resistance research, head on over to her blog...
UPDATE: We published these findings in the first batch of articles in the ARIC journal, see: Kwon et al. 2012 ARIC