The Fact-Filled Infection Control Guideline - A New Year's Wish

I'm not sure what about the above tweet got me to thinking about infection control. Before hopping on the twitter this morning, I was happily building Lego scenes with my kids and thinking about this afternoon's Indiana-Iowa basketball game (Dan - thanks for the tickets!). In infection control, there isn't a direct equivalent to the "mindless symmetry" in political journalism mentioned by Jay Rosen, which treats talking points on both sides of the aisle as equivalent without considering the facts. However, there is a similar "mindless" glossing-over of the facts by public health and society guideline committee members that appears in every HAI-guideline - recommendations based on minimal data. Instead, many (can I suggest most) of the recommendations in HAI guidelines are based on uncontrolled before-after quasi-experimental studies, expert opinion and perpetuated dogma. 

Mike pointed out a few days ago what can happen when a medical specialty, such as hospital epidemiology, recommends policies like mandatory masks for unvaccinated healthcare workers during influenza season, which are based on minimal data. I'm not even going to mention mandatory influenza vaccination for healthcare workers... But what about other claims in guidelines and by policy makers? Do we have enough evidence to support many of our interventions including most stewardship recommendations? And what about the claim that MDR-Gram negative outbreaks could be controlled if not for the unwillful healthcare worker? 

What happens when we perpetuate opinion and dogma? Although 270-page hand hygiene guidelines may make us feel good, I'm worried that they prevent us from identifying areas where we need research (hand hygiene improvement interventions, anyone?) and lead us to spending days and weeks implementing ineffective or even harmful interventions. Does anyone stop to think how these fact-challenged guidelines might be hurting our patients and eroding our reputations? It seems to me that we shouldn't be spending our political capital implementing "expert opinion" since it will hinder our efforts when we actually are armed with evidence-based interventions. Imagine that day!

So my wish for the new year is that guideline committees only include recommendations based on evidence, not opinion or dogma, no matter how hard politically that is for them in the short term. In the long term, if we insist on evidence, we might actually get evidence - someone might notice and start funding infection prevention studies. (e.g. What do you mean we don't know how to halt the spread of MDR-GNRs??) And if our guidelines are shorter and filled with evidence-based recommendations, clinicians in the field will be able to focus on interventions that actually work and not spend their valuable time on willy-nilly dogma-of-the-day recommendations that harm our reputations or worse, our patients. 

Larry

Reuters today has an article on Larry, a humanoid simulated vomiting system, which is used to analyze the effect of norovirus environmental contamination. I always like to add a picture to my blog posts, but today you'll be thankful I did not. Anyway, the synthetic vomitus used in the simulator, has a fluorescent marker that enables investigators to examine how widespread is the contamination after an episode of vomiting. Using Larry, they have found that droplets travel over 10 feet. This is important since the infecting dose of norovirus is very small, which makes it highly transmissible. As noted in the article, each droplet of vomitus has enough virus to infect over 100,000 people.

I have always wondered why anti-emetics are not available over-the-counter. If they were, quite a lot of misery could be avoided, ER visits averted, and maybe they would even provide norovirus source control by reducing environmental contamination.

Addendum (1/4/13):  NPR has added a video of Larry doing his job. It's quite impressive.

The lunacy continues

It appears that an increasing number of hospitals are requiring healthcare workers that are not vaccinated against influenza to wear masks (see a recent example here). I have yet to see any evidence to support such a policy, and I'm not even sure of the purported intent (is it to prevent infection of the unvaccinated HCW, or is it to prevent the infected HCW from transmitting to patients?).

Whatever the intent, it seems completely impractical. Wearing a mask for 8-12 hours is uncomfortable and an unnecessary distraction. I suspect it also impacts morale. So none of this makes sense to me, but neither does mandatory influenza vaccination.

Last week, the Massachusetts Nurses Association characterized the mask policy as an act of bullying. That's a strong word, but after thinking this over, I admit that I have to agree. I don't think the mask requirement has been promulgated to reduce transmission of influenza; rather, I suspect it's to punish those who don't comply with vaccination. So here we have a mandate that doesn't make sense, aimed at those who don't comply with another mandate that doesn't make sense. And the lunacy continues....

Photo:  3M

Happy Holidays from CHIP

The image above is courtesy of Stephanie Mounaud at the J. Craig Venter Institute. The fungi represented include Aspergillus nidulans (tree), Penicillium marneffei (red ornaments), and Aspergillus terreus (trunk). For more enjoyable holiday images made of fungi, check out her post here.

For a less festive take on Kingdom Fungi, see this recent Slate piece. As I used to tell the medical students when I gave my annual series of mycology lectures, “the fungi have their own Kingdom--we just live in it.”

Should we go over (to) the Cliff?

There's been a lot of talk in the US about "the cliff," specifically the fiscal cliff. Should we go over the cliff? Is the cliff just a curb?  What should we do? Panic! In response, the GOP has started pushing "Plan B," which will apparently require all Americans to receive emergency contraception if they're pregnant. This has some merit since if we no longer exist, we can't really run up the budget deficit, now can we.

Anyway, this is ostensibly an infection prevention blog, so I better get back on topic.  In the annual Christmas issue of the BMJ, investigators from the Netherlands have reported a novel method for speeding up the diagnosis of Clostridium difficile infection. The name of their novel method?  Cliff.  Just as I expected, they call or email the CDC and ask Cliff McDonald what he thinks! NO? What?

It turns out that they've trained a beagle named Cliff to diagnosis C. difficile by smell (thank goodness it's not taste). Anyone who has done an ID fellowship or even a medical internship gets pretty good at recognizing the unique small of C. diff, so we know this could work. It turns out to work pretty well. Cliff's nose detected C. difficile positive clinical samples with a sensitivity of 83% and a specificity of 98%. Not too shaggy.

Addendum: A 2007 CID study reported self-selected nurses had a sensitivity of 55% and specificity of 83% in diagnosing C. diff, while an earlier study reported that nurses had a sensitivity and specificity of 84% and 77% for predicting C. diff using factors that included odor. I would like to see Cliff dual it out with these nurses in a future trial. Daniel Uslan suggested Cliff vs "Sniff": an RCT.

"At the end of the day, the drug companies own medicine"

The title of this post is a quote by Eric Campbell of Harvard Medical School in an investigative piece in yesterday's Milwaukee Journal Sentinel. The article focuses on conflict of interest among physicians who write practice guidelines for academic societies.

Here's a summary graphic from the article:

This article is worth reading, but it's disturbing.

Trouble at the Pittsburgh VA

The Pittsburgh VA has had a recent outbreak of nosocomial legionellosis. Based upon press reports, there have been at least five confirmed cases with one death. There are also references in the media to 24 additional cases reported beginning in January of 2011 (8 of which were felt to be community onset, and 16 unknown onset—likely in the “possible nosocomial” category). CDC personnel traveled there to assist in the investigation, and full details are likely to emerge eventually. 

There is a highly charged back-story here. Reading the press reports, one immediately notices some very pointed critical comments from two internationally recognized Legionella experts. In 2006, there was an acrimonious split between the Pittsburgh VA and Victor Yu and Janet Stout (you can read their side of that story here--click through to some of the e-mails to get a flavor for just how nasty this episode was). This public dispute ended with the destruction of a massive organism bank that included thousands of Legionella strains, leading to a letter and petition being published in Clinical Infectious Diseases. And now that the Pittsburgh VA is knee-deep in Legionella without them, these two colleagues are not holding back. 

We’ve had our own history with Legionella at Iowa, and this outbreak in Pittsburgh may reiterate several important lessons we learned long ago: (1) never assume that Legionella has been eradicated from a water system, it is only suppressed to levels that cannot be detected, and will re-emerge when given the opportunity, (2) copper-silver and chlorine dioxide suppression systems work, but only if they are carefully maintained and levels of the active agent(s) are monitored (not just centrally, but also at distal sites), (3) installing a suppression system doesn’t obviate the need for regular water testing in facility that has had nosocomial cases of legionellosis, (4) there is no way to definitively determine the source of a legionellosis case if cultures are not performed on patient samples (the urinary antigen test doesn’t provide an organism for typing), and (5) all legionellosis cases that fall into the “possible nosocomial” category (onset between 2-10 days after admission) should be assumed to be nosocomial, and an appropriate investigation begun to assess for a source in the hospital water supply.

Moving away from contact precautions

Yesterday, Dan posted on the new study by Dan Morgan and others at the University of Maryland that points out yet again that contact precautions have an impact on care received by inpatients. Over the past year or so, I began to wonder about scaling back contact precautions. My colleagues, Gonzalo Bearman and Mike Stevens, recently published a paper on considerations for reducing contact precautions. Our hand hygiene rates have been >90% institution-wide for 3 years and we conduct surveillance hospital-wide for all device-related infections. And we've continued to focus on horizontal infection prevention strategies, such as chlorhexidine bathing, which we do for all ICU patients, and more recently for non-ICU patients with devices in situ. Thus, it seemed as though it was time to bite the bullet. We are now rolling out a new policy in which MRSA and VRE infection and colonization no longer require contact precautions. We'll still continue contact precautions for multidrug resistant gram-negatives, C. difficile, and ectoparasitic infestations. Feedback from healthcare workers has been very positive. And I bet we'll also make some patients happy. It should also produce less waste--we currently use 1.3 million disposable plastic gowns yearly!

Photo: Stericycle

Contact precautions: who wins, who loses?

The January issue of ICHE has some new data on the effects of contact precautions (CP) from Daniel Morgan and colleagues (full disclosure: “colleagues” here includes fellow blogger Eli, the senior author on this paper). We’ve had a lot to say on controversies around CP, and there has been increased attention to the potential for unintended adverse consequences over the past decade. It was about 10 years ago that three separate studies reported that CP resulted in reductions in both healthcare worker (HCW)-patient visits and in HCW-patient contact time. An optimist might predict that the increased focus on this issue would lead to some lessening of the impact of CP as HCWs became more aware of these effects.

The optimist would be wrong. In this study done in 2010 and 2011—prospective and multi-center, using trained research staff to observe almost eight thousand healthcare worker visits over almost 2000 total observation hours—Morgan et. al. found almost exactly the same effect. Patients in CP had 36% fewer HCW visits, and 18% less direct contact time with HCWs. Notably, the difference was seen on non-ICU wards, not in the ICU.

This study also confirms a prior finding regarding hand hygiene (HH) and CP: that HCWs are more likely to perform HH after visiting a patient in CP than someone not under CP (63% vs. 47%, respectively). As for CP generally, this effect is likely to benefit the next patient seen by the HCW (not the patient being cared for under CP). As we’ve pointed out before, one of the ethical problems with CP is that the potential risks and benefits are not distributed fairly; patients placed in contact precautions are exposed to the risks, while those not isolated experience the benefit.

Photo from Cardinal Health

Stuff we can't talk about

On this blog we discuss infection prevention, and there are several interesting articles in the January issue of ICHE that merit comment. In the aftermath of the horrors that visited a Connecticut school yesterday, though, I am thinking more about other forms of injury prevention. But apparently we can’t have a sane discussion about firearm injury prevention in the United States, or at least not while we’re mourning. Why?

I have no special expertise, so I’ll spare you my opinions. However, I do think that gun violence should be studied and prevented in the same way that we study and prevent other forms of harm. That starts with understanding some of the epidemiology. I’ll outsource this to Ezra Klein, who reviews some basic facts in this excellent post.

"If roads were collapsing all across the United States, killing dozens of drivers, we would surely see that as a moment to talk about what we could do to keep roads from collapsing. If terrorists were detonating bombs in port after port, you can be sure Congress would be working to upgrade the nation’s security measures. If a plague was ripping through communities, public-health officials would be working feverishly to contain it."

My thoughts exactly...

Source: http://xkcd.com/1147/

Thanks Teresa!

There is a collective sadness in the world of infection prevention. Teresa Horan, one of the true gems in our field, is retiring. Teresa has spent 28 years in the CDC's Division of Healthcare Quality Promotion, joining the Hospital Infections Program in 1984. She started out as the Coordinator of the National Nosocomial Infections Surveillance (NNIS) System and over the past decade has led the transition from NNIS to the National Healthcare Safety Network (NHSN). She is also an Adjunct Instructor in the Department of Epidemiology at Emory University’s Rollins School of Public Health and a Captain in the U.S. Public Health Service Commissioned Corps. Among other individual and team awards, she has received the Carole DeMille Achievement Award and the Elaine Larson Lectureship from the Association for Professionals in Infection Control and Epidemiology (APIC). 


Quoting from a CDC email, we agree that "her superb contributions to surveillance and prevention of healthcare-associated infection are singularly important to the field and an inspiration to her CDC colleagues, frontline infection preventionists, and other professionals working to improve patient safety throughout the United States and internationally." We will really miss working with Teresa and wish her a healthy and happy retirement!

Beware of dishes!

As of this week, germophobes have one more thing to worry about. A new paper in PLoS One (full text here) describes the results of a series of experiments in which dishes and forks were contaminated with a mouse norovirus and then subjected to the usual cleaning protocols used in restaurants (both machine and hand washing of the items). The results were disturbing. The various cleaning methods all left residual norovirus on the dinnerware. This is especially important since the infecting dose of norovirus may be as low as 10 viral particles.

So what to do with this information? Here are your options (from most to least risk averse):
(1)  Never eat in a restaurant again
(2)  Carry your own dinnerware with you wherever you go
(3)  Eat only at McDonald's where all dinnerware is disposable (though you could still be at a small risk from the reusable plastic tray your food items are placed on)
(4)  Eat at all your favorite places and stockpile compazine and immodium
(5)  Just cast your fate to the wind

An outbreak linked to a cardiac surgeon

The LA Times reports today on an outbreak of nosocomial Staphylococcus epidermidis endocarditis in patients undergoing valve replacement surgery at Cedars-Sinai Medical Center. The outbreak involved 5 patients, 4 of whom required replacement of the prosthetic valve. All the cases were linked to a cardiac surgeon who had what sounds like an eczematous process on his hands.

The article notes:

The infections raise questions about what health conditions should prevent a surgeon from operating and how to get the best protection from surgical gloves. Surgeons with open sores or known infections aren't supposed to operate, but there is no national standard on what to do if they have skin inflammation, said Rekha Murthy, medical director of the hospital's epidemiology department. She added that there were also no national standards on types of gloves used, whether to wear double gloves or how many times surgeons should change those gloves during a procedure.

Rekha's comments point out a few examples of the many unknowns in healthcare epidemiology. As hospital epidemiologists we are held accountable to fix problems, but often we're bereft of the answers to such basic questions. This has been a recurrent theme on this blog, and as Eli has stressed, we lack funding to perform the research to fill the gaps in our knowledge base. After this week's Infectious Diseases fellowship match, which demonstrated that few young doctors remain interested in our field, it appears that we may also eventually lack the human resources to address these problems.

Don't be one, get one...

Rick Mercer is a Canadian comedian and political satirist - his "Talking to Americans" bits were pure genius. Recently, he was kind enough to offer up two minutes of his valuable time to convince Canadians to get the flu vaccine. I agree - this could be the best public service announcement ever.

(Updated!) What you missed in Infection Prevention: December 6, 2012

1) Today's NEJM has lot's of interesting stuff.  First up, they have a review of the first cases of fungal infections associated with contaminated methylprednisolone injections in Tennessee. The report covers 66 case patients with 21 having confirmed Exserohilum rostratum infection and 1 having confirmed Aspergillus fumigatus infection.

2) Next up, NEJM has a perspective piece from the FDA that highlights infections secondary to contaminated antiseptic products including iodophors, alcohol products, CHG and quaternary-ammonium compounds.

3) And finally from the NEJM, Thomas Sandora and Donald Goldmann have a perspective piece outlining their suggestions for preventing hospital outbreaks of antibiotic-resistant bacteria. Most of what they offer is standard infection control dogma from the  - it's the healthcare worker's fault for not washing his/her hands diatribe - to the suggestion that a "parsimonious set of interventions aimed at reducing exposure to antibiotics may have the greatest effect on resistance." They even included a table of the suggested parsimonious stewardship interventions (below). I don't believe that any are backed by more than uncontrolled quasi-experimental studies or expert opinion. (Please correct me if I'm wrong!) Might they have recommended funding studies of these interventions instead?  It's hard enough to be a hospital epidemiologist in 2012 marketing the few evidence-based interventions at our disposal without laying the burden of making us defend interventions based on pure speculation on our backs.  Oh well.

4) There is a report in today's Ottawa Citizen by Helen Branswell that nicely outlines two NDM-1 outbreaks that occurred (October 2011 and January 2012) in Toronto. The article covers an study published in ICHE and another in CID. The latter described the transmission of the NDM-1 between E. coli and Klebsiella species in the same patient.

5) Last-but-not-least, check out this story in NPR that highlighted an innovative research study out of Michigan State University. Researchers modeled the spread of murders in Newark, NJ as an infectious disease and discovered that murder appears to be transmissible like an infectious pathogen. They are now figuring out why some neighborhoods are more resistant to homicide and how they might "vaccinate" populations to reduce murder. Pretty cool and Go Sparty!

Infection Control Image of the Day

I know, this image made the rounds on the internets last year, but the infection control risks were not highlighted. Yes, this image is real and don't try this at home.

The ghosts of the "prior room occupant"

"Well, you know, Doc, when something happens, [it] can leave a trace of itself behind. Say like, if someone burns toast. Well, maybe things that happen leave other kinds of traces behind. Not things that anyone can notice, but things that people who "shine" can see….I think a lot of things happened right here in this particular hotel over the years. And not all of 'em was good."

-From the movie The Shining, 1980 

I’m reviewing papers for a talk I’m preparing on “control of multiple drug resistant gram negative rods (MDR-GNRs)”. So I’m looking again at a set of studies that always scare me (even more than a Stephen King novel)—those that demonstrate that a variety of bad bugs (C. difficile, MRSA, VRE, and MDR-GNRs) can be “left behind” after a patient is discharged, poised to colonize or infect the next occupant of that hospital room. It is a scandalous indictment of current hospital disinfection practices that patients must be haunted by the pathogens of the previous occupant of their hospital bed! 

There are still some practical (and financial) hurdles that must be overcome before new disinfection technologies (UV light, H2O2 vapor, antimicrobial surfaces, etc.) become standard of care. In the long run, though, I think that’s where the future lies—excellence in cleaning will remain important (organic debris will always require removal), but for microbial eradication in the environment, these technologies are going to replace our existing, more rudimentary approaches.

The World Needs a Strong CDC!

For the fight against new or emerging pathogens like CRE or tracking huge outbreaks, as seen with the recent contaminated steroid injection disaster, we need a strong and well-funded CDC. Apparently, many former CDC Directors agree. In a recent Politico Editorial, William H. Foege (1977-83); Julie Gerberding (2002-08); Jeffrey P. Koplan (1998-2002), James O. Mason (1983-89); William L. Roper (1990-93); and David Satcher (1993-98) expressed great concern that the CDC isn't properly prepared for the threats they are required to face.

The former Directors used the recent steroid-injection case to highlight how stretched thin the current CDC is. Recently, over 300 staff have been pulled in to help respond to the fungal outbreak leaving multiple food-borne illness outbreaks, novel H3N2v swine flu emergence in the Midwest and global issues like SARS-like viruses arising in the Middle East all without an adequate response from our front line public health defenders. You should read the complete editorial.  I agree with everything they say, well, except when they say "Americans depend on a strong CDC." I think it's the whole world.

image source: wikipedia

Stopping CRE: Where there's a will, there's a way?

Why is it that the DOD can ask for more money to fight their wars but CDC can't?  It seems to me that the fight against resistant bacteria is a war! - enp

I was interviewed by Peter Eisler of USA Today about a month ago concerning the recent NIH KPC Outbreak. His investigative report on carbapenem-resistant Enterobacteriaceae (CRE) was just published today and I found it a very good read.  The report centers around a CRE outbreak that began four years ago at the University of Virginia Medical Center and continues there to this day. The article is particularly interesting when you focus on the quotes from all of the other HAI-prevention folks in the article.  However, I also thought as I was reading it, what would Dan and Mike have highlighted if they'd posted on this same article?

I suspect that Dan would have wanted to highlight how difficult infection control becomes when gene/plasmids cross species during outbreaks and how this strongly impacts case definitions as you investigate. He might also point out how this limits the utility of whole genome sequencing, since the plasmids merrily skip from one species to another.  I think that Mike might have pointed out that the vertical control barriers, like nasal PCR, set up to prevent MRSA transmission are not very effective at preventing the spread of non-MRSA pathogens like CRE. He might suggest that a continuous and relentless focus on horizontal measures, like hand-hygiene, would be most effective.  Dan and Mike would both have been correct, but I have a different take...

My take is that CDC is on the wrong side of this debate and this has me very worried. Now, I don't remember exactly what was said about HIV during the 1980s, but I suspect there was a realization that something needed to be done and that significant investments would need to be made in its treatment and control. I'm not suggesting that CDC should flame fires of panic, but I wonder how long we can rely on the same old, largely ineffective, tools for outbreak control - patient isolation, subpar environmental control, inadequate hand-hygiene improvement bundles, lack of effective and novel antimicrobials - before CDC asks for help...and more funding.

So here are some select quotes from the article with my concerns bolded:

CDC:

"We're working with state health departments to try to figure out how big a problem this is," says the CDC's Srinivasan, noting that his agency can pool whatever incidence data states collect. "We're still at a point where we can stop this thing. You can never eradicate CRE, but we can prevent the spread. ... It's a matter of summoning the will."

The rest of us:

"In the Chicago area, where scores of CRE infections have been found since 2008, studies show that about 3% of hospital patients in intensive care carry the bacteria, says Mary Hayden, director of clinical microbiology and an infectious-disease doctor at Rush University Medical Center. Those same studies have found CREs being carried by about 30% of patients in long-term care facilities." "We have to think about a new approach, a regional approach, to controlling these organisms, because … no facility is an island," Hayden says.

"My concern is that there aren't a lot of methods in our tool kit that are significantly effective in curbing the spread of these infections," says Eli Perencevich, a professor and infectious-disease doctor at the University of Iowa's Carver College of Medicine. If unchecked, "these (bacteria) are going to greatly impact the kind of surgeries (and) treatments we can have," Perencevich says. "We're entering the post-antibiotic era; that's a very big problem."

"If you look at the current pipeline of antibiotics (in development) … none of them really is going to be active against these bacteria," says Gary Roselle, director of the Infectious Diseases Service for the Department of Veterans Affairs health care system. "The reality is, (CRE infections) are remarkably difficult to treat, they often have bad outcomes … and they're increasing nationally," adds Roselle. "I'm assuming this is going to get worse, and there likely won't be new antibiotics to treat it in the near future, so the focus has to be on prevention."

"So even if I had a perfect program to stop all patient-to-patient transmission in the hospital, the maximum impact I could have would be a 60% reduction in prevalence," says Brian Currie, the hospital's vice president for research and an assistant dean at the affiliated Albert Einstein College of Medicine.

"We have continued to have patients with CREs that are related to this (first) event," Costi Sifri, the hospital epidemiologist at UVA, says. "We haven't been able to close the door on this. ... I'm not sure you ever can."

References:
Peter Eisler, USA Today, 11/29/2012

Maryn McKenna, Wired, 8/24/2012

Prevention and Public Health Fund, still a political football

We’ve blogged before about threats to the Prevention and Public Health Fund. Lest anyone think that a silly election would keep prevention funding safe from the axe, this piece, citing “GOP sources”, outlines the three most likely cuts to the Affordable Care Act that lawmakers hope to secure as part of a debt-reduction deal. You guessed it, the Prevention and Public Health Fund remains a prime target. From the article:

The Prevention And Public Health Fund
The prevention fund was designed to help local communities combat disease and promote wellness. Republicans deride it as a “slush fund.” 

Initially set at $15 billion, GOP leaders convinced the president and Democratic leaders to chop it by $6.25 billion in the payroll tax cut deal early this year. Having sensed that Democrats are willing to reduce its size, they’ll hope to continue chipping away at it.

Check out Eli’s post from earlier this year, as a reminder of how much of the CDC’s budget would be at risk if prevention funds are further slashed without a commensurate boost to the CDC's core budget. 

Addendum: I forgot to link to this list of the foolishness funded by this crazy slush fund. "Improving capacity to to detect and respond to infectious diseases threats", "enhancing the ability of state and local authorities to detect outbreaks", what kind of fool thinks these activities might be important?!

Photo from Wikipedia Commons

Montgomery County is now in the loop!

The next time a contagion sweeps through the NIH Clinical Center, Montgomery County officials will be on it, thanks to a new agreement between NIH, Maryland and Montgomery County. The back-story is that Montgomery County officials were unhappy that they weren’t informed promptly about the deadly KPC outbreak at NIH.

This raises the question of when a hospital should communicate with public health officials (and the public generally) about fairly common SNAFUs. At any given time, 5-10% of hospitals are dealing with clusters or outbreaks of multiple-drug resistant gram negative bacteria (KPCs, ESBLs, MDR-Acinetobacter, etc.), and even more are in the midst of MRSA, VRE, fungal or other outbreaks. The population at risk during these outbreaks is pretty clearly defined, and doesn’t include the general public. General notification can generate media frenzy, free-floating panic and anxiety, and waste precious time and resources for the personnel trying to contain the outbreak (responding to media, doing damage control of various types, etc.). Furthermore, most states don’t include common healthcare associated bacterial pathogens among their legally reportable diseases.

However, as state and local public health officials become increasingly involved in HAI issues, it would be wise to establish explicit criteria for when healthcare facilities should report clusters and outbreaks. Provided they have sufficient funding (which they currently do not!), public health departments should play a critical role in coordinating responses to HAI outbreaks, which often involve multiple healthcare facilities in a region (across the spectrum of acute, long-term, and long-term acute care).

So when do you think a hospital should notify their state and/or local public health department? Two cases of MRSA infection in the NICU? A single serious post-operative Group A strep infection? New introduction of a carbapenemase into the ICU?

Oh, and Happy Thanksgiving!

Riding the epidemic curve to glory, WGS edition

One reassuring lesson all healthcare epidemiologists learn is that every outbreak will, eventually, come to an end. The trick is to prevent outbreaks in the first place, or to recognize them early enough to intervene effectively. Many outbreaks, though, are recognized as they peak and are entering the “downhill” part of the epidemic curve. Any interventions prescribed by erstwhile epidemiologists are then, in retrospect, credited with helping to contain the outbreak (even if said interventions were completely idiotic). This phenomenon was described by Dr. Alexander Langmuir, the father of the CDC’s Epidemic Intelligence Service, as “riding to glory on the downhill slope of the epidemic curve”.

Now we can add the performance of whole-genome sequencing (WGS) to the list of activities that epidemiologists can “ride to glory” as the key to outbreak control. As WGS becomes faster and more affordable, reports have been published in NEJM, Science Translational Medicine and Lancet Infectious Diseases suggesting that WGS can be the key to real-time or “actionable” information to help contain outbreaks (due to MRSA, KPC-producing K. pneumoniae, and MRSA, respectively). As we’ve pointed out previously, though, it isn’t at all clear that WGS was important to real-time outbreak management, or that WGS is ready for prime-time and coming soon to a hospital near you.

Why? For any technology to see widespread adoption in clinical diagnostic laboratories, there must be sufficient automation (including of the analysis and interpretation of the massive amounts of WGS data), and it must provide a substantial advantage over existing testing approaches.

Which brings us to the more important question: given our crude approaches to outbreak control, how does WGS provide any immediate advantage over other same-day typing methods? Does the added discrimination really make a difference in whether we decide to isolate or cohort patient X, decolonize healthcare worker Y, or close unit Z to new admissions? These questions are particularly pertinent when we don’t yet understand the “within host” variation in genotype and how “within” versus “between” host variation can be applied to determine direction of transmission (or even the fact of transmission). Eli recently sent me a link to this interesting discussion of the Lancet ID report, which addresses some of these issues. 

The bottom line is that we have a relatively few crude tools for outbreak response: enhanced basic practices (e.g. hand hygiene, environmental disinfection), active surveillance, isolation, cohorting (of patients and/or HCWs), decolonization of carriers (both HCWs and patients), removal (temporarily or permanently) of HCWs implicated in transmission, closure of units, mitigation of any identified common sources, etc. The level of discrimination provided by WGS is a great research tool, and will undoubtedly help in retrospectively piecing together the most likely outbreak scenarios--but for now I’m not convinced it has much advantage over other typing methods for guiding real-time outbreak investigation and management.

Don't let authors control for factors in the causal pathway!

A downside of being an epidemiologist who thinks about antibiotic resistance 24-7 is that eventually it's hard to read the literature for fear of seeing another paper where authors make a critical mistake.  It's unfortunate, because the review process should catch these common errors and at least make the authors mention limitations in their discussion sections.  A case in point is a recent paper by Chen et al. in CID that sought to assess the impact of MRSA SCCmec type and vancomycin MIC on treatment failure. In this case, treatment failure was defined as all-cause 30-day mortality, persistent bacteremia, or recurrent bacteremia. They provide nice graphs showing higher mortality for hospital associated-MRSA strains (SCCmec type I, II, III) and for strains with vancomycin MICs > 2. So far, so good. But then, I looked at their multivariable model.

As expected, they controlled for septic shock or severe sepsis in their model. They should not have done this. If it were a comparative effectiveness study assessing various treatment outcomes, it would be appropriate to collect severity of illness including evidence of sepsis before treatment initiation and control for it in the model. However, Chen's study was only looking at outcomes based solely on strain differences. Thus, they should never have controlled for shock or sepsis. How else would a bacteremic patient die if not through sepsis? For a longer description of why controlling for factors in the causal pathway is suboptimal, see my post from 3/19/2012. I have pasted the key sections below. Note: We have been writing letters and review articles in CID pointing this issue out since the year 2000.

____
March 19, 2012: My first ever publication, and in some ways still my favorite, was a letter to the editor of CID that I wrote in 2000 pointing out a common flaw in outcome studies of infectious diseases. In the letter, I discussed a paper that looked at the outcomes (death) associated with methicillin-resistance in patients with S. aureus bacteremia. In the analysis, the authors controlled for septic shock in their regression model. I pointed out that shock is in the causal pathway between infection and death and, therefore, should not be controlled for in regression in models. This would be like controlling for car accidents when looking at the association between cell phone use and death. In infectious diseases, if you remove shock from the causal pathway, it is hard to see how you might otherwise die.

The error of controlling for intermediates is frequently repeated in ID outcome studies when, for example, authors control for illness severity using the APACHE score. If the APACHE is measured after the infection manifests, this variable would be in the causal pathway and should not be controlled for in the regression model. The APACHE should be measured before the infection manifests, as we did here. Jessina McGregor and JJ Furuno (both now at Oregon State) published a nice systematic review on optimal methods for ID outcome studies in CID back in 2007. Wouter Rottier (with Marc Bonten) just published a meta-analysis looking at the impact of confounders and intermediates (factors in the causal pathway) on ESBL-bacteremia outcomes. (JAC, March 5, 2012) I highly recommend that you read these studies prior to undertaking an ID outcome study.

Q: What are Iowans doing to prevent hospital-acquired infections?

A: Quite a bit, actually. Thanks for asking!

Just last week, University of Iowa researchers Tara Smith, Marin Schweizer, and Phil Polgreen all sat down with Iowa Public Radio's Ben Kieffer (picture to the left) to discuss the latest science in HAI prevention including the epidemiology of MRSA in animal populations, the importance of environmental control in hospital settings and the latest hand-hygiene surveillance technologies.

Click on over to have a listen!

Shocking: Another review of the evidence finds flu vaccine has no miracle powers

The Science section of the New York Times this week had an article on a new report regarding influenza vaccination. This report (free full text here) from the University of Minnesota is the kingdaddy of all analyses on influenza vaccination--a 3-year project funded by the Alfred P. Sloan Foundation that reviewed 12,000 papers back to 1936 and involved interviewing 88 influenza experts. The report is 123 pages without appendices and includes over 500 references. 

Here's my summary of the chapter on vaccine performance of the two major vaccines (trivalent inactivated influenza vaccine [TIV] and live attenuated influenza vaccine [LAIV]):

Population	TIV	LAIV
Children	Inconsistent evidence of protection	High level of protection (83%)
Healthy adults	Moderate protection (59%)	Lack of evidence of protection
Elderly	Paucity of evidence for protection	Inconsistent evidence of protection

What about use of the vaccine in healthcare workers? This can be found on pages 57-58 of the report and I have pasted below the important discussion of the HICPAC recommendation regarding offering influenza vaccine to healthcare workers):

The 2006 statement on influenza vaccination of healthcare personnel (HCP) from the Healthcare Infection Control Practices Advisory Committee (HICPAC) and ACIP illustrates potential concerns with using a grading scale.[63] This recommendation used the HICPAC grading scale, which is similar to the GRADE criteria in that it provides a structure for ranking the evidence. All recommendations were approved by the HICPAC and the ACIP. This document has been used widely as evidence to support HCP vaccination policies, including mandating vaccination. It offers six recommendations, and one was deemed to have the highest possible evidence, category IA. Category IA recommendations are “strongly supported by well-designed experimental, clinical, or epidemiological studies.”[63] The recommendation in the HICPAC document that received a category IA rating states:  “Offer influenza vaccine annually to all eligible HCP to protect staff, patients, and family members and to decrease HCP absenteeism. Use of either available vaccine (inactivated and live, attenuated influenza vaccine [LAIV]) is recommended for eligible persons. During periods when inactivated vaccine is in short supply, use of LAIV is especially encouraged when feasible for eligible HCP.”[63]

This recommendation is supported in part by this key summary statement in the HICPAC document: “Vaccination of HCP reduces transmission of influenza in healthcare settings, staff illness and absenteeism, and influenza-related morbidity and mortality among persons at increased risk for severe influenza illness.[64-67]” In the first study cited, the authors did
not find a statistically significant reduction in patient mortality associated with HCP vaccination, after adjusting for covariates.[64] In the second study, the authors concluded that “we do not have any direct evidence that the reductions in rates of patient mortality and influenza-like illness that were associated with HCW vaccination were due to prevention of influenza.”[65] In the third study, vaccination did not reduce the episodes of self-reported respiratory infection or the number of days ill with a respiratory infection, but it did reduce the time employees were 58 unable to work because of a respiratory infection.[66] In the fourth study, the authors reported reductions in absenteeism and illness among HCP that were not statistically significant.[67] The authors did, however, report serologically confirmed vaccine effectiveness of 88% for H3N2 and 89% for influenza B across three influenza seasons.[67] Since only two of the four studies cited provide some support for the HICPAC statement and the others no support, it is unclear how the quality of evidence in these studies received a category IA evidence grade. Another review conducted in the same time frame by the Cochrane Collaboration noted that the two RCTs cited in this recommendation were at “moderate risk of bias.”[68] They concluded that “both elderly people in institutions and the healthcare workers who care for them could be vaccinated for their own protection, but an incremental benefit of vaccinating healthcare workers for elderly people has yet to be proven in well-controlled clinical trials.”[68]

So this report questions the evidence base for even recommending influenza vaccination to healthcare workers. Yet, SHEA's position is so over-reaching that it calls for mandating vaccination and firing noncompliant healthcare workers. This is now the fourth independent analysis that does not support the SHEA position statement (read about the others here, here and here).

I continue to be fascinated by the post-modern disdain for evidence. A marvelous example from this week is the shock and utter disbelief suffered by Mitt Romney and his staff on learning that Barack Obama won the presidential election, despite nearly every poll indicating that Romney would lose. I guess I naively thought that somehow epidemiologists were immune to such bias but SHEA's flu vaccine position suggests otherwise.

One of the recommendations in the Minnesota report is that "scientifically sound estimates of influenza vaccines’ efficacy and effectiveness must become the cornerstone of policy recommendations." Amen. And it's time for SHEA to retract its policy!

MRSA in water treatment plants! Panic?!

There is a new study just published in Environmental Health Perspectives that is getting a lot of media attention (here and here and here). The (open-access) study by University of Maryland researchers identified MRSA (and MSSA) in water samples collected during 2009/2010 from two mid-atlantic and two mid-western water treatment plants. They found that 50% of samples contained MRSA and 55% contained MSSA. Among the MRSA strains, 83% were SCCmec type IV and 15% were SCCmec type II, while 68% were pvl gene positive. USA100, USA300 and USA700 PFGE strain types were identified.

Sounds pretty scary, and if you don't read carefully, you might conclude that you shouldn't drink municipal water. However, it appears that most of the MRSA/MSSA was detected in "influent" or pretreatment samples, which were 83% positive, while 17% of post-treatment "effluent" samples were positive and only 8% were MRSA positive. This suggests that water treatment is effective in eliminating S. aureus, so keep drinking the water.

Note:  The positive samples in the effluent were collected during periods when seasonal chlorination was not taking place. Thus, if your municipality uses chlorination, there is likely little S. aureus risk. Also, we should ask if we can generalize beyond this 4-facility sample.

Image Source: EPA via CDC

Not another damn map!

I'm pretty sick of maps. We have blue states, red states, periwinkle states, pink states and Ohio-colored states. Then we have light green states, green states and dark green states that show how many cases of Exserohilum meningitis have been identified in each. (Don't you wonder why there are no meningitis cases in Massachusetts? Seems like they might have known something!) If that weren't enough, it's time to start worrying about this map...

Come to think of it, I wish some of the other maps looked more like this map. Would make things a little less predictable, no? Texas, the same color as California - haven't seen that in awhile. 

New twist in the outbreak due to contaminated pharmaceuticals

The New York Times is reporting today that another manifestation of the outbreak of fungal central nervous system infections has appeared. Some patients are developing epidural abscesses at the site of the steroid injection. Particularly worrisome is that some of these abscesses have developed while patients are on antifungal therapy.

Meanwhile, the epidemic continues to expand. The CDC is now reporting 395 cases of central nervous system infection, 9 cases of septic arthritis, and 29 deaths across 19 states. In addition, betamethasone and cardioplegia solution from the implicated compounding pharmacy have also grown multiple species of Bacillus in culture.

Lastly, on the weekend before election day, it's hard not to think about politics. And this outbreak highlights the tensions between business and regulatory oversight, a common theme in our political landscape today. This article published in Salon takes a look at that issue with regards to this outbreak.

Hikers and hand hygiene

A new paper in the American Journal of Infection Control from SUNY Upstate focuses on hand contamination in wilderness hikers. Hand cultures were performed on 72 hikers and 31% were found to have fecal contamination. Now I won't belabor how this may have happened, but as an infection control expert, I would recommend packing some Purell for future treks.

Fungal meningitis outbreak still unfolding

The fungal meningitis outbreak continues to expand. At this point, there are 347 cases of central nervous system infection (meningitis or stroke) and 7 joint infections, with 25 deaths. The outbreak now involves 18 states with an estimated 14,000 patients exposed to contaminated methylprednisolone from the New England Compounding Center. Exserohilum has been recently cultured from unopened vials of the product and is the predominant pathogen in the outbreak.

Here are some recent articles on the outbreak:

• Wall Street Journal (10/28/12)
• Boston Globe (10/28/12)
• New York Times (10/28/12)

Best Hand Hygiene Signs Ever!! - This time I really mean it!

OK, back on topic. The Allegheny County Health Department developed a series of hand hygiene signs based on literary classics way back in 1999 to stop a shigellosis outbreak.  The project, called Literary Classics: A New Kind of Reading Material for Public Restrooms won the prestigious J. Howard Beard Award from the National Association of County and City Health Officials. The nine hand-hygiene signs were based on work by authors Jane Austen, Charles Dickens, Judy Bloom, Mark Twain and others. All are available here in JPG or PDF. Amazing.

h/t Melissa Ward

Presenteeism - Don't Come to Work Sick!

Mike has posted numerous times on the problem of presenteeism in healthcare workers. The Wall Street Journal has a nice article/video on "the art of calling in sick" and why it's important to stay home to protect your co-workers. The post includes sage advice from Iowa's own Loreen Herwaldt, who advises influenza and pertussis vaccines and good hand hygiene. She says that "the 24-hour rule pediatricians preach to parents—that a child with the flu should stay home from school or day care at least 24 hours after the fever and symptoms go away—usually holds true for adults too." Importantly, she also mentions that the rules would differ for healthcare workers who are sick.

Thanks Jenn!

As we alluded to previously, the inaugural IDWeek was a success.

Sadly, one of the people instrumental in making it a success is leaving the Society for Healthcare Epidemiology of America (SHEA). As Executive Director, Jennifer Bright, MPA, has led SHEA through a period of unprecedented growth. 

A partial list of SHEA milestones under her direction were outlined in the e-mail announcement of her departure, and include: (1) successful introduction of a new SHEA Spring educational and research conference, (2) the inaugural IDWeek, (3) establishment of the SHEA Education and Research Foundation, (4) establishment of the SHEA Research Network, (5) introduction of the Antimicrobial Stewardship in Practice online course, (6) development and implementation of regional HAI training courses, (7) successful ACCME reaccreditation, (8) the SHEA International Ambassador Program, (9) roll-out of the SHEA young investigator epi-project competition and awards, (10) partnership with Medscape, (11) several years of increasingly successful annual meetings, including the 5th Decennial International Conference on HAIs, and (12) a steady increase in SHEA membership. 

In our opinion, Jenn was the most successful executive director in SHEA’s history. We will miss her personally, and SHEA will miss her guidance. Good luck in the future, Jenn!

The boiling frog and antibacterial resistance

I just returned from IDWeek in San Diego (as many of you have). I will say that it wasn't the same as having a standalone SHEA meeting - fewer impromptu hotel lobby discussions and few Europeans - but it had its moments. For one, the sessions were better attended - I think many ID physicians who would normally not travel to a spring SHEA meeting, wandered into infection prevention sessions. Perhaps they direct the infection control committee at their hospital and wanted an update. It was also interesting to see the community protesters out in force; we don't get that kind of attention in infection prevention...but perhaps we should.

The Lyme disease guideline protesters did get me thinking about community action and infection control and why we don't get that kind of attention.  The early nineties saw plenty of HIV/AIDS protests and now that MRSA alone is associated with similar mortality (imagine if you add MSSA, VRE, KPC, NDM-1, ESBL, MDR-acinetobacter), I wondered if and when the public and clinicians would wake up to a world without antibiotics and get angry.  I know there are differences between the HIV and MDRO epidemics. Yes, HIV is a single virus that struck young people down in the prime of their lives, but with MDROs we're facing a world with unsafe surgery (or no surgery), death during neutropenic fever and perhaps fewer transplants. So why is there such a huge difference in our responses?

I think a major reason that MDROs attract little attention is that the emergence of resistance occurs too gradually. A useful metaphor in this case is the boiling frog.  The story goes that if you place a frog in boiling water, it will immediately jump out, but if you place it in cool water and slowly turn up the heat, it will be boiled alive. Since carbapenem-resistance Gram-negatives didn't just appear one day like HIV, we see less response to the problem. We had penicillins to protect us and when they failed we had cephalosporins and then when they failed we had the carbapenems. The problem is, we stopped investing in antibiotic discovery 30 years ago, and there is nothing after carbapenems. So now, we must wait 10-20 years for new antibiotics and we MUST invest in infection prevention research and implementation. I think MDROs are due for a protest movement, but it probably won't appear. We all love a good warm bath, now don't we.