Tuesday, September 27, 2011

Cuyahoga Moment - and the End of Antibiotics

Cleveland, even now I can remember
'Cause the Cuyahoga River
Goes smokin' through my dreams
-Randy Newman, "Burn On"

Dan's ICAAC-"Destroyer of Bundles" post last week was surprising for several reasons: (1) because my talk was an overview of which components of the bundles were most effective and never suggested bundles didn't work, i.e. we don't know exactly which components contribute most to the success of bundles and (2) because he mentioned ye olde burning river, the Cuyahoga.

We actually owe a lot to the Cuyahoga River. The Cuyahoga caught fire numerous times dating back to 1868, but it was the 1969 fire that caught the public imagination through a Time Magazine article that described the river as one that oozes rather than flows.  It was this 1969 fire and the attention associated with it that led to the creation of the EPA and the Clean Water Act. In fact, Paul Krugman, recently suggested that the Cuyahoga fire was the start of Environmentalism in this country. Because of the fire, the Cuyahoga and Lake Erie and numerous other bodies of water in the US have sprung back to life.  Thank you Cuyahoga and thank you Cleveland.

So, why am I writing about the Cuyahoga in an HAI blog?  Because I've been waiting for years for our "Cuyahoga Moment" that will start the process of the US taking antibiotic resistant organisms and antibiotic drug discovery seriously. Perhaps, someday we might even see an agency created that would be charged with guiding the creation and stewardship of antibiotics. How 'bout the Agency for Antibiotic Protection? I first thought perhaps VRE or MRSA, then VRSA would have gotten serious attention and I even thought the recent run of KPC and NDM-1 would have done the trick.  No such luck.  We are still left with an underfunded CDC that can barely afford to do simple quasi-experimental studies, a pharmaceutical industry that has closed down most antibiotic discovery efforts and an NIH that focuses almost entirely on non-bacterial pathogens.  I probably shouldn't even mention non-human use of antimicrobials.  Sadly, I suspect it will take a shuttering of a transplant program or a whole hospital or something far far worse to alert the public and the Government.  What do you think it will take?

Burn on, big river, burn on...

On the physical examination

Here's a TED talk (or perhaps more appropriately an anti-TED talk given the subject matter) by Abraham Verghese that ends with the audience awarding him a standing ovation.

Sunday, September 25, 2011

The dirty curtain story

We recently began a study of microbial contamination of hospital privacy curtains (a study funded by one of several manufacturers of an antimicrobial fabric). The comparative study is ongoing, but the “baseline” sampling confirmed what Curtis Donskey’s group has already described: hospital privacy curtains are often contaminated with bacterial pathogens (the main additional findings from our study have to do with how quickly the curtains become contaminated (spoiler alert: very quickly), and how some organisms persist on curtains over time). Figuring the results might generate some interest among a few attendees, and perhaps spark some useful discussion of this and other environmental infection control issues, we decided to submit the baseline data to ICAAC. We had yet to learn this valuable lesson:

Never underestimate the media’s fascination with the presence of bacteria on inanimate objects.

Stethoscopes, ties, white coats, rings, cell phones, you name it. If you want media attention, grab some swabs, head up to your nearest patient care unit, and find some new object to culture! By Friday after ICAAC, the story had been picked up by CBS News, Reuters Health, Fox News, etc., etc. (I can’t bother with all the links, just type “privacy curtain” into Google News). It has turned into a minor annoyance, as we seek to put these findings into perspective in our own hospital, and navigate the obvious conflict-of-interest inherent in managing the findings of a study sponsored by an industry that has a vested interest in the outcome.

So, what are the implications of this study? Most importantly, consider privacy curtains to be like any other high-touch surface in the patient environment, and perform hand hygiene after contact with the curtain. This can be a real challenge in an ICU environment that doesn’t have private rooms, so other approaches seem wise as well: more frequent cleaning/changing of curtains (in most hospitals they are changed only when visibly soiled), use of a “pull rod” or other plastic object to allow one to pull the curtain around without touching the fabric (the plastic surface can be more easily disinfected), or use of other barriers (e.g. glass doors that turn opaque). There’s a burgeoning interest in antimicrobial fabrics (not just for this purpose, but for healthcare worker clothing, etc.), and these may also play a role. Finally, Mike’s prior posts on single patient rooms are pertinent—well-designed private rooms can obviate the need for frequent use of privacy curtains.

Wednesday, September 21, 2011

"You destroyed the bundles"

While at ICAAC over the weekend, I attended a symposium on infection prevention bundles. This excellent session began with Marc Bonten doing a (very) critical review of the literature in support of bundles for VAP and MRSA prevention, after which our own Eli Perencevich discussed how one might begin to parse out which elements of our current bundles are the most important. After these two compelling talks, a young man (an infection preventionist from Italy, I think) approached the microphone with a declaration and a question: “You have destroyed the bundles! What shall we do now?”

I’m hard-pressed to answer this question, except to say that it would be wise to refrain from starting with bundles that have one element that is hugely expensive and of uncertain effectiveness, lest we end up wasting millions on expensive screening tests when “horizontal” infection control measures will suffice.

In other news, R.E.M. has broken up after 31 years. R.E.M. was my soundtrack through medical school and residency training, and their pre-1994 repertoire is still in heavy rotation in my head and on my iPod. So in honor of R.E.M. and in honor of Eli, destroyer of bundles, I give you R.E.M.’s Cuyahoga:

Tuesday, September 20, 2011

Good design vs. bad bugs

Graphic:  TM Osborn Associates
A new paper in Critical Care (full text here) attempts to evaluate whether improved ICU design has an impact on transmission of epidemiologically important pathogens, such as VRE and MRSA. The authors compare the proportion of patients acquiring these pathogens before and after an ICU moved from an open unit to one with all private rooms, and also compared this to another ICU that maintained an open floor plan during the study period. In the ICU that moved to all private rooms, the proportion of patients acquiring a targeted pathogen fell from 23% to 5%, whereas in the control ICU there was no change (20% in the corresponding pre-move period, and 18% in the post-move period). So the authors conclude that better ICU design leads to fewer infections.

The study has a number of problems--it's small and relatively short. Moreover, in the intervention ICU, prior to the move the patients were sicker, had received more antibiotics prior to ICU admission, and had a higher prevalence of multidrug-resistant organisms on admission. All of these factors could be responsible for the higher proportion of patients acquiring the bad bugs in the "old" ICU, making the "new" ICU look better than perhaps it was. Also, importantly, hand hygiene compliance was significantly higher in the intervention ICU than in the control ICU in the post-move period, though one could argue that improved hand hygiene was due to better design (e.g., better availability of sinks).

While I remain unconvinced regarding the conclusions of this particular study, it seems to me that for many reasons having ICUs with all private rooms is a good thing. Infection prevention, since time immemorial has been about separating clean from dirty and infected from uninfected. It just makes sense--kind of like not wearing the same dirty white coat to work every day.

Saturday, September 17, 2011

Antibiotics: a market failure

Photo:  Summit Total Health
There's a very nice article in the October edition of the Atlantic on the problems of antibiotic development and antibiotic resistance viewed from an economics perspective. Full text of the article can be found here.

Tuesday, September 13, 2011

A four billion year head start

A recent article in Nature confirms that the sound you hear, late at night, when all else is quiet….is the sound of bacteria laughing…laughing at the idea that humans can win the antimicrobial resistance battle. An excerpt from the abstract describes their findings after isolating ancient bacterial DNA from Canadian permafrost:

“We report targeted metagenomic analyses of rigorously authenticated ancient DNA from 30,000-year-old Beringian permafrost sediments and the identification of a highly diverse collection of genes encoding resistance to β-lactam, tetracycline and glycopeptide antibiotics. Structure and function studies on the complete vancomycin resistance element VanA confirmed its similarity to modern variants. These results show conclusively that antibiotic resistance is a natural phenomenon that predates the modern selective pressure of clinical antibiotic use.”

Pulling out antibiotics that bacteria could defend against 30,000 years ago is kind of like….bringing a sword to gun battle.

Papers you should read, September 2011

We know. Postings have been light these past few weeks. Hey, we are getting ready for ICAAC and IDSA. So cut us some slack, already...(joking)

OK, in a matter of full disclosure, I have conflicts of interest with both of these papers, so following our standard practice of not critiquing papers where we have conflicts, I will leave the interpretation of each paper to you, our dear readers.

Click to enlarge: Frequency of non-prescription use of antimicrobials in the general population
Dan Morgan, who was our invited contributor on Veterans Day, has published a review of world-wide, non-prescription antimicrobial use in this months Lancet ID.  The review included 117 articles including 35 community surveys published between 1970 and 2009. I've pasted a summary figure above.

Co-blogger Dan has a paper coming out in ICHE (ahead of print) surveying IDSA's EIN Network of ID clinicians on their pre-op screening and decolonization practices for S. aureus. The survey included 488 respondents, who had knowledge of their hospital's pre-op screening. Overall, 60% screened for S. aureus with 47% screening for MRSA only and 13% for all S. aureus. Less than 20% screened extranasally. Screening method was led by PCR (36%) followed by standard culture (30%) and chromogenic agar (27%). Additionally, 52% decolonized with 31% decolonizing MRSA carriers, 8% decolonizing S. aureus carriers and 15% decolonized irrespective of colonization status. To find out more, you need to read the paper!

Thursday, September 8, 2011

Clinical Microbiology Camp!

In February of this year, a large group of clinical microbiologists, employees of laboratory diagnostic companies, and an FDA representative met for a symposium in Houston (it was entitled, “Camp Clin Micro”!). The symposium consisted of a series of facilitated discussions of hot topics in diagnostic microbiology. I enjoyed the give-and-take during these sessions, and thought the interaction between hospital laboratory directors and industry scientists was especially valuable. The written summaries of this symposium are now available free as a supplement to the Journal of Clinical Microbiology, including a summary of the session on the role of clinical microbiology in infection prevention.

Monday, September 5, 2011

Hot topics in the news

Over the past week, there were 2 studies related to infection prevention that attracted a fair amount of attention by the mainstream media.

A paper in Psychological Science (full text here), looked at whether various messages on signs placed near sinks in hospitals could have an impact on handwashing compliance. Of note, the two authors of the study have no medical training--they're professors in business schools. They randomly assigned one of three signs to be posted near 66 soap dispensers, with the following messages:

  • Hand hygiene prevents you from catching diseases
  • Hand hygiene prevents patients from catching diseases
  • Gel in, wash out (control message)
They hypothesized that healthcare workers are overconfident and overestimate their own invulnerability, thus a message that focused on protecting the patient rather than themselves would be more effective. Two experiments were performed: in the first, the effect of the messages was measured by the volume of soap used in the dispensers; in the second experiment, conducted 9 months later, covert observers who worked on the study units recorded hand hygiene compliance by direct observations. The results were a 33% increase in volume of product usage, and a 10% increase in hand hygiene compliance at sinks which had the sign that focused on protecting patients. Although these results were statistically significant, this study has many flaws. The methods section of the paper tells us little about the setting--the type of hospital, the size of the hospital, on how many patient care units the signs were posted, or the type of care units involved. The experiments were brief, each lasting only 2 weeks. We are not told how many healthcare workers were involved; this is particularly important since the number of hand hygiene observations was very small (a total of 322 opportunities before the intervention and 245 opportunities after the intervention). When the results were categorized by practitioner type (nurse, physicians, ancillary staff), the numbers of observations were  extremely small. All in all, it's hard to put much stock in this short, small study in a single hospital.

The other study in AJIC, cultured the clothing (white coats, nurse uniforms, and OR scrubs) of a convenience sample of 135 healthcare workers  in a hospital in Jerusalem. Cultures were set up to detect S. aureus, Enterobacteriaceae, Pseudomonas spp and Acinetobacter spp. Overall, 50% of the cultures were positive for one of the above pathogens. Acinetobacter was most common, found on 32% of white coats, 38% of nurses uniforms, and 43% of OR scrubs. So we have another study that documents what we already know: healthcare worker clothing is commonly contaminated. But the key question remains as to whether the organisms can be transferred to patients. More on that here.

Friday, September 2, 2011

Conflicts of Interest: Beware, you're human!

We've each posted frequently on conflicts of interest, financial and otherwise. Here, Dan Ariely talks briefly about scientific conflicts of interest - they aren't all financial - and what hope we might have to protect ourselves from other people's and our own conflicts. Dr. Ariely is the James B. Duke Professor of Psychology and Behavioral Economics at Duke University and a founding member of the Center for Advanced Hindsight.  I wonder if his Center is really good at determining if a CLABSI is secondary or not. Enjoy.