Wednesday, November 30, 2011

Breaking...bacteria are everywhere!

As we recently found with our hospital curtain study, the media are fascinated with the fact that bacteria can survive on inanimate objects. The latest culprit, as outlined in this LA Times article, is paper. Paperless electronic medical records would seem a great solution to this problem, were it not for those germ-laden computer keyboards!

The solution is simple, fortunately. Just make sure that the last thing you touch prior to contact with a patient is an alcohol hand sanitizer.

Monday, November 28, 2011

Deus ex machina: duabus partibus (Part Two) - Tiny Magnets

With infectious diseases, there is always another miracle around the corner.  The problem is that the miracle typically stays around the corner. Come on down...The next contestants in the search for a miracle cure are..."tiny magnets."

Researchers in Switzerland are developing nanomagnets that could remove harmful compounds (e.g. bacteria) from the blood. The technology involves magnetized nanoparticles coated with carbon and pathogen-directed antibodies. The plan is that the antibodies attach to the pathogens and then the whole compound is removed from the blood with hemodialysis. Sounds pretty exciting. Probably exciting enough to hold off on further investments in infection prevention research, not!

Source: Technology Review (MIT): 11/28/2011

Friday, November 25, 2011

Taking hand hygiene monitoring to a new level

Photo: Richard Lee, New York Times
CS = current shift; WR = weekly rate
A new study in Clinical Infectious Diseases details the use of video monitoring in North Shore University Hospital's medical ICU to improve hand hygiene compliance. Video cameras were placed in hallways and every patient room with remote video monitoring performed by observers in India.

In the initial phase of the study (16 weeks), no feedback was given to healthcare workers in order to determine the baseline rate of HH compliance, which was found to be incredibly low at 6.5%. In the second phase of the study (16 weeks), realtime feedback was provided by electronic boards (shown in the photo), with more detailed reports emailed to unit leadership 3 hours after start of each 12-hour shift and at the end of shift, as well as a weekly summary. During this period, hand hygiene improved to 82%. The third phase of the study (75 weeks, interventions identical to the second phase) showed the overall compliance rate to be 88%.

So here we have a very interesting study with compelling results. Unfortunately, the authors do not provide any data on infection rates. Given that we believe that hand hygiene and infection rates are linked, if any group were ever in a position to prove this dogma, it is these investigators with data on 400,000 hand hygiene opportunities over a 2 year period.

Some additional information on the study can be found in the Fixes blog at the New York Times web site. In that piece the cost of the surveillance system is delineated--$50,000 for the video equipment with $1,000 per month for "maintenance." We are not told if "maintenance" is the cost of the wages for the persons doing surveillance, who are employed by a company in the business of remote video auditing.

The authors point out that the healthcare workers were all informed that hand hygiene would be monitored, and all feedback was done at the aggregate level without identification of individual healthcare workers during the study. But I'm left with an uneasy feeling. It seems somewhat absurd to me to devote this level of resources to a single element, albeit an important one, of patient care. Even more absurd is that the real work is being done in a third-world country (whose public health infrastructure is so primitive that half of the population is forced to defecate in the open) by human observers making very low wages in order to make marginal improvements in the quality of care in an ICU setting (where a great deal of futile but incredibly expensive care is delivered) in the richest country of the world. I just can't wrap my arms around that juxtaposition.

Thursday, November 24, 2011

I'm thankful for the CDC

Last night, I stumbled across a link to this piece:

Somehow I read all the way through it before I saw who had written it. Then it all made sense. Like a bad penny, Betsy McCaughey, turns up yet again. Since it's a holiday and I would prefer to stay in a joyful mood, I won't write anything about her, but refer you here to see our previous postings about her.

So on this Thanksgiving Day, I'm thankful for the CDC. Over the course of my career, I have come to know many people who work there, particularly in the hospital infections group. They are simply a great bunch--smart, hard-working, dedicated people who do great work with little recognition. The CDC has been working in the area of healthcare associated infections for over four decades and it's difficult to imagine what healthcare epidemiology would look like today were it not for these folks.

Wednesday, November 23, 2011

In case you need another reminder to wash your hands...

Photo: Medical Tips Blog
There's a new paper in PLoS One on the biogeography of public restrooms (full text here). In other words, some investigators cultured various surfaces in 12 bathrooms on a university campus and then mapped out areas where groups of bacteria (e.g., skin flora, gut flora, genitourinary tract flora, and soil organisms) were found. The results were quite predictable. Soil organisms were dominant on floor surfaces (brought in via shoes), skin organisms dominated on faucets, and fecal organisms dominated on toilet surfaces. Of note, toilet flush handles were found to harbor both fecal organisms and soil organisms, and the authors postulate that the soil organsims are deposited there when people flush toilets with their feet in order to avoid touching the flush handle with their hands.

Ironically, one of the sponsors of the study was the Howard Hughes Medical Institute, the foundation started by an infamous germophobe.

So for all of you using the bathroom in an airport, train or bus station on this Thanksgiving eve:  Wash your hands! And turn off the faucet with a paper towel.

Paul Offit and the Dangers of the Anti-vaccine Movement

Paul A. Offit, MD, talks with Eli Y. Adashi MD, Brown University and Medscape, about the history and hazards of the anti-vaccine movement. "Residual damage, 40% of parents are now delaying or withholding one or more vaccines from the children." You can read our prior posts on Dr. Offit here.

Collateral damage: The ongoing measles epidemic in Quebec.

Tuesday, November 22, 2011

Novel H3N2 Influenza in Iowa: More bad news from pig country

PIGS: Portugal, Italy, Greece and Spain
When it rains, it pours.  Dr. Patricia Quinlisk, medical director for the Iowa Department of Public Health, announced today that a novel H3N2 influenza A strain had infected three Iowa children.  Evidence points to one child transmitting the virus to the other two. There have been seven prior cases of this strain, all in the US (Maine, Indiana and Pennsylvania) and all apparently linked to animal exposure, which makes the Iowa cases unique. All but one case has been in children under 10 years old, suggesting prior year exposure to H3N2 might be protective. Perhaps it's ironic that this novel swine strain was first transmitted from human-to-human right here in pig country.

Sources: Des Moines Register 11/22/2011 and Winnipeg Free Press 11/22/2011

Addendum: Iowa just added 2,300 jobs, which I think is about double our human population.  I think two job seekers family members (update:  actually just in for Thanksgiving) from other states even moved in with Dan this past weekend.  Getting crowded here, which might be increasing the flu transmission.

Actual update on the virus: "In these ten most recently reported cases, the virus has been a swine H3N2 virus with the M segment gene borrowed from the 2009 H1N1 virus. Essentially a hybrid – a new reassortant virus - that until this summer had not been seen before." source: Avian Flu Diary

More bad news from pig country

It is kinda funny moving back to the Midwest after spending almost 20 years on the east coast. To be specific, I grew up in the East North Central region (Great Lakes States) and now find myself in the West North Central (Great Plains States); never mind that Iowa isn't actually in the Great Plains.  People are always asking why I would move back or what's it like there in flyover country or the heartland or Middle America - I just smile and say that "all the women are strong, all the men are good looking and all the children are above average." Most of the over-stressed, over-crowded coastal folk have at least heard of Garrison Keillor, so that usually changes the conversation...

The Atlanta Braves' new mascot?
OK, so Maryn McKenna has a nice post over on her Wired Superbug blog discussing two studies looking at MRSA in US retail meats. She first reviews a study by Blake Hanson in Tara Smith's U. Iowa lab that found MRSA in retail pork including spa type t034 (ST398). 

The second paper from University of Maryland College Park included testing of 694 samples of retail ground beef, ground pork and ground turkey in the DC area. The somewhat surprising finding was the 17% of turkey and 17% of pork samples were contaminated with MRSA.

The funny part of McKenna's post was that she said that Tara Smith's work was particularly important because "they probably know ST398 better than any other US team looking at the strain" (OK, that's good) "and unlike the other research groups, they are embedded in pig country." ???

We can all agree that Iowa produces a lot of pork, but what about Virginia which is #4 or #5 in turkey production.  I guess, we can refer to people in Alexandria as being from turkey country. Oh, and Georgia is #1 in broiler production, so people from Atlanta are now from chicken country.  I guess, this re-transplanted Midwesterner is becoming overly sensitive...

Addendum: Strictly speaking, PIGS countries are Portugal, Italy, Greece and Spain which are in the midst of an economic crisis. Iowa's unemployment rate sits at 6% and is operating in a close to balanced budget.

Sunday, November 20, 2011

Dogs on call

Many hospitals have pet therapy programs. At VCU, the Dogs on Call Program is a part of the Center for Human-Animal Interaction, which conducts research on the therapeutic effects of interacting with animals. Click here to view a video about the program.

Now I'm sure that these programs make some of us in Infection Prevention nervous. But as I have argued many times before, an infection-free hospital stay may not be the be-all and end-all for every patient. Sometimes infection prevention is trumped by other facets of patient care. And this, I think, is one of them.

Friday, November 18, 2011

Weekend Update: Almost Thanksgiving Edition

Batterio killer al II Policlinico: due bambini fuori pericolo
Il Secondo Policlinico: Source NapoliToday

Leggi tutto:
Diventa fan:
Just some random stuff for your enjoyment while you're running around trying to get everything ready before you (a) are invaded by family/friends or (b) invade family/friends or (c) both.

#1: Recently, there was a serious outbreak of Acinetobacter infections in the neonatal care unit of Batterio killer al II Policlinico: due bambini fuori pericolo
Secondo Policlinico di Napoli, which resulted in the closure of the unit/department/hospital depending on the report you read. English or Italiano

h/t Maryn McKenna

#2: November 14-20, 2011 is Get Smart About Antibiotics Week. SHEA, APIC and IDSA all support this effort and so do we. See also the CDC Get Smart website.

#3: CDDEP has a new ResistanceMap showing US antibiotic prescriptions per capita at the state level. Each state's use is listed.  The worst offender: West Virginia which uses approximately 1.2 antibiotic prescriptions/person. Alaska has the lowest use with about 0.5 prescriptions/person. Where does your state rank? Check out CDDEPs map!

#4: Scientific America has an interesting post by Katherine Harmon reviewing two recent Science papers.  There is new evidence as to how S. aureus, E. coli and P. aeruginosa respond to stress and how this new knowledge might be exploited to enhance existing antibiotics. Shatalin et al. Science 18 November 2011: Vol. 334 no. 6058 pp. 986-990 and Nguyen et al. Science pp. 982-986


Thursday, November 17, 2011

Deus ex machina and antibiotic resistance

Last night, I watched a movie with my young kids. The "plot" involved friends traveling with one of their moms to Japan and then getting lost.  It was a bit scary for my kids. I was even a bit worried, since I had no idea how they would ever be found, but this was a Disney movie, so I knew it had to have a happy ending. Just when it all looked lost, the mom realized she had placed a tracking device under her son's skin when he was a baby and she also happened to have the required GPS tracking device in her purse.  Boom! Kids found, all was well. Ridiculous. Sure, my kids were happy, but where is the lesson there?

Flashback to a conversation I had three weeks ago with a visiting professor in general internal medicine.  She is a very well-known clinical researcher in oncology, an area that is well-funded unlike antibacterial resistance, and I wondered what she thought of the lack of new antibiotics in the pipeline, the rise of novel resistance mechanisms in Gram-negatives like NDM-1 and how she thought this would impact oncology.  Her response? Her jaw dropped.  She thought that there was always another antibiotic in the pipeline or in the ID physicians back pocket to pull out and save her patients. It had actually never occurred to her that we have had close to zero new classes of antibiotic in decades.  It was like life was a Disney movie and we could just pull a new antibiotic out of the air to save the day. Ridiculous.

But, whose fault is that?  I don't think it is the oncologist's fault. Is it the ID physician's fault who always sounds so smart and attempts to prove her usefulness by pretending that a polymixin is a useful new antibiotic! Is it the funding agencies that have ignored bacterial infections since the 1960's and certainly since the 1980's?  Is it the pharmaceutical companies that closed most antibacterial drug discovery units or governmental rules (patents) that bias against antibacterial investments?  Of course, the answer is all of the above and more.  All I can offer is that we have to stop pretending that some magical antibiotic will be discovered. There will be no 10x20 to rescue our patients.  I would settle for 2x20 or how about "1 good one by 20".

As ID physicians, I think we need to stop pretending that we have effective antibiotics. We need to be more honest about the hopelessness of the situation. If a well-trained practicing oncologist isn't aware of the problem, we aren't doing our job. When we face facts, we will have a better chance of convincing the public and government to actually invest in infection prevention and antibacterial drug discovery. This isn't some Disney movie.

Wednesday, November 16, 2011

One patient per room, eh

The Canadian Standards Association released new guidance for hospital construction today. Consistent with AIA guidance, the standards call for single patient rooms in all new hospital construction and renovation in Canada. As Mike has blogged, somewhere Madame Necker is smiling.

Tuesday, November 15, 2011

The user experience

I was going to start this post by explaining how busy I’ve been, why I haven’t posted in a while, blah, blah, blah. Then I realized I would undercut that immediately by revealing that I’ve just finished reading Walter Isaacson’s biography of Steve Jobs. I read it on an iPad, of course, so didn’t realize it was over 600 pages long until I had finished it and saw it on display at a Detroit airport bookstore yesterday.

I highly recommend it. I enjoyed learning more of the story behind the personal computer revolution that still seems so recent to me (I vividly recall using the Commodore 64, and then the Mac, both of which were released while I was in college). But I mostly marveled at the fierce vision (and meanness) of Jobs, and how he was still able to motivate people and channel this vision into so many great products.

Does it contain any lessons for healthcare epidemiologists and infection preventionists? I hesitate now, because I hate facile comparisons of other industries with healthcare delivery (yes, I understand that we can learn lessons from the airline industry or FedEx, but I’ll be more receptive when FedEx starts delivery packages that arrive at their drop-boxes with multiple co-morbidities, or when Delta can fly me from Boston to Moline without a missed connection due to multiple small system failures—explaining why I was browsing Detroit airport bookstores yesterday afternoon). I was taken, though, with Jobs's laser-like focus on “end-to-end integration”, and maintaining control of the entire user experience (hardware, software, and content):

“His quest for perfection led to his compulsion for Apple to have end-to-end control of every product that it made…This ability to integrate hardware and software and content into one unified system enabled him to impose simplicity”

Simplicity means that users can actually enjoy, and benefit from, the products in an easy and intuitive way. While digital enthusiasts and computer geeks might want malleable open systems, most of us just want to be able to download that cool song we heard yesterday onto our music player without using too much profanity in front of our kids.

Meanwhile, the U.S. healthcare system might be the least integrated “system” in the world. Hence the “user experience”, to borrow one of Steve Jobs's favorite phrases, “truly sucks.” Having just navigated an elderly family member’s transition through acute care, assisted living, skilled care, and home again, I can honestly say that having some inside knowledge of the system doesn’t help much—it still sucks. Many patient safety initiatives, including infection prevention initiatives, are akin to software patches, temporary fixes to problems that wouldn’t exist if we had a truly integrated system—integrated not around RVUs, profits or operating margins, but around the patients’ simple goal: to get better, and not to be harmed in the process.

Wednesday, November 9, 2011

I'm having a (hand-hygiene) moment

We have been working on a hand hygiene surveillance project here in Iowa City. One of my collaborators, Heather Reisinger, just went through and listed all possible "moments" for hand hygiene listed in the various guidelines, which I've pasted below.  Yes, I know there is overlap.

However, I think this list exemplifies why we fail in our infection prevention efforts. How can we take such a simple thing as hand-hygiene and make it this complicated? How can the WHO Guidelines on Hand Hygiene be 270 pages long?!?!?! How can we have directive after directive and keep making it more complicated?

Solution: the Iowa City ONE Moment For Hand Hygiene: After you touch anything

And no, you don't need the before since if you haven't touched anything after you practiced hand hygiene, then there hasn't been a moment for hand hygiene.  It is only AFTER you touch something/anything! that you have to practice hand hygiene.

Take off gloves - you touched them, wash your hands! 

Did you touch a patient, then use hand rub and then exit the room? Do you need to practice hand hygiene? NO; but did you touch anything on your way out, such as a door handle? If yes - practice hand hygiene! 


16 Moments For Hand Hygiene

___entering patient room
___before touching a patient
___before handling medication
___before clean/antiseptic procedure
___before putting on sterile gloves
___after removing gloves
___after exposure to body fluid
___after visibly dirty/soiled
___moving from a contaminated body site to another body site during the care of the same patient (say that one three times while rubbing your belly and head)
___after touching equipment or patient surroundings
___after touching a patient
___exiting a patient room
___before eating
___after using the restroom
___when preparing food
___after delivering food (if worker touches patient, bed linens, or objects in the room)

20 years ago, Magic Johnson changed the AIDS epidemic

Twenty years ago, Magic Johnson announced his retirement from the NBA because of HIV infection.  I remember that moment well. I was in medical school and we all knew that HIV could infect all people.  However, at the time little national attention was given to the broad risks of the disease, since the general public and politicians thought that only homosexuals, Haitians, hemophiliacs and heroin addicts (the 4 H's) could contract the virus.

Magic's honesty and subsequent appointment to the National Commission on AIDS changed the whole discourse. Magic didn't have to do what he did.  He didn't have to go public. He could have retired and probably lived his life. He took a risk and it paid off for all those with HIV and AIDS. Back then, we all thought this was a death sentence for Magic, like it was for so many before him. Magic's role in changing the conversation probably saved his life and certainly saved many other lives. Thanks Magic.

Personal note:  My med-school friend's (Laura Jana) mother, Dr. June Osborn, was the chair of the National Commission on AIDS and played a significant role in getting Magic appointed to Commission and assisted Magic as he framed his message.  At the time she said "there is no question in my mind that Magic Johnson has achieved a breakthrough that will result in a fundamental sea change. I have been frantic to get the message across to children and youth, and I know damn well that I can't do it. He can." June has been a wonderful mentor to me over the years and I'm proud to know someone, such as June, who has made such an important public health contribution.

Sunday, November 6, 2011

There must be a pony in here somewhere...

Before mandatory reporting and pay-for-performance, and before zero became the only acceptable infection rate, it was OK to have somewhat subjective, imperfect definitions for healthcare associated infections. No longer!

Never fear…HICPAC has working groups now grappling with three different definitions: for CLABSI, VAP and SSI (full disclosure: I’m a member of these working groups). Here are just a few desired attributes of any newly-modified HAI definition:

  • Must have excellent performance characteristics (most importantly, nearly 100% specificity) when compared with gold standards (note: gold standards do not yet exist).
  • Must consist of only objective measures that can be collected by all NHSN participating hospitals, and that are amenable to electronic reporting and easy validation.
  • Must demonstrate excellent concordance with clinical definitions of infection, so as not to lose credibility with frontline clinicians (note: because of the subjectivity of clinical definitions, this attribute is not consistent with the attribute above).
  • Must not be subject to “gaming”, even by the most creative hospitals (note: even supposedly “objective” measures, like culture and antibiotic use data, are subject to practice changes in response to pressure to reduce HAI rates).
  • Must not result in public or political perception that modifications were made in an attempt to lower HAI rates (i.e. “define our way to zero”).

So, keeping these in mind, feel free to submit any suggested changes to current definitions, in the comments section!

Friday, November 4, 2011

The Affect Heuristic

We've discussed conflicts of interest and bias frequently, particularly in regards to guidelines.  Bob Centor has a nice post today that discusses the affect heuristic and how it might impact clinical guidelines.

The affect heuristic suggests that a good feeling or emotion towards a situation (i.e., positive affect) would result in a person having a lower risk perception and higher benefit perception than supported by an unbiased look at the data. I think this is closely related to confirmation bias, which we have written about frequently, as well.

His recommendation for selection of guideline panels - choose strong methodologists who are non-experts - is one worth pondering.

Wednesday, November 2, 2011

Disgust and Infection Prevention

That's disgusting! (source: wikipedia)
Just came across this great article in the journal Philosophical Transactions for the Royal Society B, titled "Why Disgust Matters." In the paper Valerie Curtis of the London School of Hygiene and Tropical Medicine argues that the human feeling of "disgust" evolved to motivate infectious disease avoidance. She suggests that a better understanding of disgust could be harnessed to combat the behavioural causes of infectious and chronic disease such as diarrheal disease, influenza and even smoking.

You could imagine that more knowledge around "disgust" or what motivates good behavior (covering your face when you sneeze or washing your hands) could greatly improve infection prevention in hospitals.

Curtis V, Phil. Trans. R. Soc. B 12 December 2011 vol. 366 no. 1583 3478-3490 (abstract) (full text)

Related BBC Article by Health Reporter Philippa Roxby

Tuesday, November 1, 2011

Conflicting Results in Clinical Trials: the APC Example

Dan posted last week on activated protein C (Xigris) being withdrawn from the market.  David Rind (Evidence in Medicine blog) has posted his thoughts on what might have been behind the initial positive study in 2001 and subsequent negative studies.  It is worth a read.

David Rind: APC and Conflicting Trials (10/29/2011)

Odds and ends

Here are a few odds and ends that I've been mulling over--some related to infection prevention, some tangentially related, and some, well not at all.

  • A new paper in the International Journal of Obesity looks to see whether response to influenza vaccine is impacted by obesity. This is important since during the H1N1 pandemic obesity was found to be a risk factor for morbidity and mortality. Interestingly, in this study of nearly 500 participants the investigators found that antibody production is not affected by BMI, but as BMI increases there is a significant decrease in antibody detected at 12 months. The implications of this paper could be huge given the increasing prevalence of obesity in the US.
  • I just read Steven Berk's recently published book, Anatomy of a Kidnapping, on a quick trip to Vermont. Berk is an infectious diseases physician and medical school dean, who was kidnapped at gunpoint from his home in 2005. He writes that equanimity helped him to stay cool through the entire ordeal. Though this may have saved his life, I think it robbed some of the emotion from his prose, and I was left with little connection to what should have been a very compelling story. And if I were not on a plane without anything else to read, I would have closed the book for sure when he articulates his view that individuals should be allowed to purchase and own assault weapons.
  • Coldplay's new album, Mylo Xyloto, is simply amazing. I can't quit listening to it. It's already setting records for the rate (there's a tie to epidemiology!) of digital downloads it's receiving.
  • Dick Wenzel, the most famous hospital epidemiologist since Semmelweis, has in his "retirement"  published a novel and danced the tango for charity. This week he will debut in VCU's production of the musical Grease. He plays the DJ, Vince Fontaine. He still has a day job, too--this week he's attending on the Transplant ID Service.