Saturday, March 31, 2012

New tools for shoe-leather epidemiologists

Here's an interesting article in Salon on the use of social media to identify people at risk of STDs. The article contains an interview with Peter Leone, an Infectious Diseases physician at UNC, who discusses exploring social networks to expand the circle of at-risk persons instead of just relying on conventional  methods for contact tracing.

Graphic: Salon

Friday, March 30, 2012

The utility of medical meetings

There's a provocative commentary in this week's JAMA by John Ioannidis on medical conferences. His argument is that "medical congresses may serve a specific system of questionable values that may be harmful to medicine and health care." Some of the issues he notes include:
  • The huge carbon footprint generated by attendees' travel
  • The dissemination of misinformation due to abstracts that are not well reviewed, sometimes inaccurate, and many of which are never ultimately published as full-length articles
  • Giving opinion leaders disproportionate influence
  • Over-the-top exhibit halls
  • Industry sponsored satellite meetings
He concludes by calling for research on the best ways to disseminate information and educate physicians. I have to admit that I usually don't learn a great deal at meetings, but it sure is fun to catch up with old friends! 

Photo: The Serra Group

Thursday, March 29, 2012

800,000 Reasons to Market Your Science

800,000  That's the number of manuscripts in science and engineering published each year.  If you read a paper a day, a noble goal, you could read 0.05% of the published papers.  Imagine if you are a primary care doc who had to keep up in multiple clinical areas or worse yet, a science journalist.  How could you manage?

JournalWatch from qfever.com
Now let's turn that around.  Let's say you're a scientist who has important data you want to share.  How can you make your one very very important manuscript stand out among the 800,000? Your magnum opus represents a mere 0.000125% of all papers published in the last 365 days.  To make you feel better, we could assume equal likelihood that a paper is published on any given day and find that only 2192 papers are published per day. So your paper would represent 0.05% of papers published on the day it appears.  Better act fast since things get worse if you consider a whole week. You get my point.

So why should anyone read your paper? More accurately, how can you convince me to read your paper if I don't even know it exists?  Answer: You have to market it.  Some authors at some institutions who publish in some journals (AJIC not ICHE) are lucky, since someone does the marketing for them.  If you're not so lucky, you and your colleagues have to do the marketing.  If you're looking for the how and why we should market our science, look no further than this month's issue of Nature Materials. It includes an editorial, commentary and interview of Marc Kuchner, astrophysicist and author of a new book titled Marketing for Scientists, each discussing the importance of science marketing.

This isn't just about selling your paper or raising your profile, nor is it limited to increasing your chances of NIH funding, but rather it has very large public health implications.  We have spent years in infection prevention quietly studying methods to prevent the spread of resistant bacterial pathogens and reducing surgical infections with very little notice and certainly very little funding.  By nature we are type-A, quiet and hard working folk, who don't want to rock the boat.  Well, guess what?  It ain't working.

To emphasize our lack of voice...Q: Who are the two most prominent public voices in quality improvement / infection prevention?  A: Peter Pronovost (critical care) and Atul Gawande (surgery).  Thank goodness someone is speaking up!

So what can we do?

1) When you publish a paper on antibacterial resistance or infection prevention, advertise it.  Get on twitter or Facebook. Call your local paper's science reporter if they still have one, work with your hospital or university to do a press release, and demand the journal do a press release (see point #2)

2) Call ICHE and SHEA and insist on a press releases for your paper, even if it's not published in ICHE (joking on that last part). Currently, ICHE does a little monthly email thingy on 1-2 papers - not going to work!  Ask them to emulate what APIC and AJIC do - much better!

3) Call your representative and ask why no one is doing anything about new antibiotics and why there are all these infections without treatment.  Ask them why there is no direct funding from CMS for infection prevention services for acute and long-term care facilities. Use your science to start the conversation - say - "look what I just found!"

4) Start a local chapter of ID physicians, ICPs, microbiologists and others that focus on raising awareness for antibacterial resistance.  Work together to communicate resistance trends in your locality and the findings of your research. (I know I'm dreaming)

5) Get your state and local health departments involved - send them your papers. I bet they know a way to get newspapers interested in resistance.

We aren't just scientists, we are stewards of our science. If you care enough to do the study and publish the paper, you should care 10x more that someone reads and uses your science!

...that's all I got for now, see you on twitter...

(live) image source: http://www.qfever.com/journalwatch.html

Wednesday, March 28, 2012

TB: "In some areas we have probably already lost the battle"

A recent article in the British newspaper, The Observer, reports on the disturbing situation with multi-drug resistant tuberculosis. The article points out the current situation of increasing MDR cases is a result of loss of funding for TB, mismangement of infected patients, and the terrible situation of so few effective antibiotics.

Photo: Alexander Joe/AFP

Tuesday, March 27, 2012

Sorry guys! Not wearing a white coat makes us more stupider

My new favorite study.  Researchers at Northwestern University explored the impact that clothes have on our thinking processes. Specifically, they looked at the impact that wearing a lab coat has on attention-related tasks.  While it is well documented that what one wears impacts the perceptions and reactions of others (See Molloy's new Dress for Success), less research has been completed on the impact clothes have on the wearers themselves.

In three related randomized trials, Adam and Galinsky explored the science of "enclothed cognition" which suggests that people are influenced by (a) physically wearing specific clothes and (b) the symbolic meaning of the clothes.

In the first study they randomized 58 students to randomly wear a lab coat or their street clothes.  Subjects were then given the Stroop task where they had to quickly state whether a string of letters were colored red or blue with some incongruent trials thrown in with the word "RED" written in blue and "BLUE" written in red. While each group took the same amount of time to complete the tasks, the subjects wearing lab coats made half as many errors on the incongruent trials. Thus, it appears that wearing a lab coat improved selective attention.

In the second (N=74) and third studies (N=99), they investigators explored the impact of the clothes "meaning."  They divided the cohort into three random groups: (1) wearing a "doctor's" lab coat; (2) wearing a painter's lab coat and (3) seeing or identifying with a doctor's lab coat. The outcome they tested was sustained cognition by showing subjects identical photos except for four minor differences and asking them to find the four differences. Test yourself using the photo below while wearing and not wearing your white coat. (You can click to enlarge the photos)



The results were very interesting. The subjects in a doctor's coat found 20-30% more differences in the pictures than subjects in a painter's coat. Thus, wearing a lab coat improves sustained attention but only if it is a certain kind of lab coat - namely a doctor's white coat - the meaning of the coat matters.

So where does this leave us?  First, I would want to see how persistent this effect is. Does the effect wear off very quickly after the "white coat ceremony"?  Does it work immediately after you put on the white coat but then work less effectively by the end of rounds?  Of course, does it have to be a "doctor's coat" in particular or can we slowly wean clinicians off their white coat addiction while maintaining the cognitive benefits with a creative replacement, say, a doctor's cummerbund?

Source: Adam H and Galinsky AD. J Soc Psych 2012

ESCMID-SHEA Training Course: Potsdam 1-4 October

Looks like it's going to be a busy fall.  In addition to IDWeek (October 17-21), ICAAC (Sept 9-12), SMDM (October 17-20), there is the annual ESCMID-SHEA Training Course in Hospital Epidemiology in Potsdam, Germany.

The course is made up of 3 modules: the Healthcare-associated Infection Prevention and Management Core Module, the Applied Infection Control Module and the Healthcare-associated Infection Advanced Epidemiology Module. Course fees are 1290 Euro for Society members, which includes hotel and food. Of note, 1290 Euro = $1721.2470 US if you sign up...exactly.......now!  Oh, shucks, too late it just changed.

Update: 28 March at 1pm CT: Cost is now $1715.57

The course coordinators are Marc Bonten, Bart Gordts, Jan Kluytmans, Leonard Mermel and Andreas Voss. The course faculty spans the globe with five faculty from The Netherlands and two faculty from The Iowa.  Sign up now!


  • Marc J. M. Bonten, Utrecht, The Netherlands
  • Ben Cooper, Oxford, UK
  • Markus Dettenkofer, Freiburg, Germany
  • Bart Gordts, Antwerpen, Brussel
  • Loreen Herwaldt, The Iowa, USA
  • Arno Hoes, Utrecht, The Netherlands
  • Jan Kluytmans, Breda, The Netherlands
  • Leonard Mermel, Rhode Island, USA
  • Eli N. Perencevich, The Iowa, USA
  • Evelina Tacconelli, Rome, Italy
  • Christina Vandenbroucke-Grauls, Amsterdam, The Netherlands
  • Andreas Voss, Nijmegen, The Netherlands
  • Andreas F. Widmer, Basel, Switzerland



Saturday, March 24, 2012

Today is World TB Day

  • 1/3 of the world's population is infected with Mycobacterium tuberculosis
  • Nearly 1.5 million people globally die due to tuberculosis yearly
  • With regards to deaths due to infection, TB is second only to HIV

Friday, March 23, 2012

Not too shabby for an ID doc

Jim Kim, Ophelia Dahl, and Paul Farmer, co-founders of Partners in Health
Today President Obama nominated Jim Yong Kim, the president of Dartmouth, to be the president of the World Bank. Trained as an infectious diseases physician, Kim co-founded Partners in Health, and worked for many years with that organization to provide health care to impoverished people around the world. He also led the World Health Organization's HIV program.

I first learned of Dr. Kim several years ago when I read "Mountains beyond Mountains," a book about Paul Farmer and the start of Partners in Health. It's a wonderful book that should be required reading for anyone who works or wants to work in health care.


Addendum (3/25/12): Here's a good piece by Ezra Klein on why Kim is a good choice for this position.


Photo: Dartmouth Life

US District Court Judge Orders FDA to take Action on Antibiotics in Animal Feed

In a story Maryn McKenna broke last night, Judge Theodore Katz of the Southern District of New York (largely NYC) has ordered the FDA to take action on it's 1977 finding that antibiotics in animal feed impact resistance in human populations. For 35 years, various interests have blocked further efforts to limit 'growth promoting' antibiotics in feed. This lawsuit, brought by Natural Resources Defense Council with the Center for Science in the Public Interest, Food Animal Concerns Trust, Union of Concerned Scientists, and Public Citizen, sought to restart the evaluation process and move away from the current voluntary participation supported by FDA.

All right, nothing more here. Head on over to Maryn McKenna's SuperBug post to get the rest of the story. She's also provided links to her prior posts on the topic. Awesome!

Tuesday, March 20, 2012

Can Influenza Outbreaks Be Controlled? Call for Papers

Influenza Research and Treatment is a peer-reviewed, open access journal that has an up-coming special issue on influenza outbreak control. The lead editor is Lewis Radonovich from Gainesville. Submit early and often. After all, Illinois is voting today.

They are looking for manuscripts exploring methods for controlling influenza outbreaks at the population level including TIV or LAIV vaccines, emerging vaccines and new technologies, barriers to or evaluation of vaccine effectiveness, school-located influenza vaccine programs (SLIV), prophylactic pharmaceutical interventions and treatment regimens and non-pharmaceutical interventions.

Important Dates:
Manuscript Due: Friday, 15 June 2012
First Round of Reviews: Friday, 7 September 2012
Publication Date: Friday, 2 November 2012

Source: Influenza Research and Treatment Call for Papers

Today's Profile in Science

Today's New York Times has a lengthy interview with Arnold Relman and Marcia Angell, former editors of the New England Journal of Medicine. The interview is part of the paper's Profiles in Science series. For many years they have pointed out conflicts of interest in medicine and argued for improvements in our healthcare system. Here's a video of part of the interview:

Monday, March 19, 2012

Ouch!

The latest issue of Annals of Internal Medicine has a case report of a surgeon who incised a lesion on a patient's lip. While disposing of the scalpel, the surgeon stuck his finger. Subsequently, the surgeon developed a lesion at the site of the injury which didn't heal over a 6-week period. Turns out, the patient's lesion was a syphilitic chancre, and the surgeon developed a syphilitic chancre on his finger. Given the increase in syphilis that we are currently seeing, occupational transmission of syphilis shouldn't be a surprise. But I suspect the surgeon had some 'splaining to do to his significant other.

Photo:  DentalOrg.com

Optimal Epidemiological Methods for Infection Prevention Studies

I've spent the last 12+ years writing about epidemiological methods for conducting risk-factor, outcomes and intervention studies of hospital-acquired infections. Instead of always reviewing the latest and greatest studies, I thought it might be fun to look back at some of the epi-methods papers that many of my colleagues and I have published since 2000. I think we've made some important contributions to infection prevention research, so it's kinda fun to look back at these. Over the next month or so, I hope to review other epi-methods topics that I think are particularly relevant to the study of hospital-acquired infections.

A decade ago, Anthony Harris and Yehuda Carmeli (and other folks) outlined optimal control-group selection in risk-factor studies for antibiotic resistant infections. (see here, here and here) Prior to these important studies, authors would frequently use patients infected with the susceptible organism as the control group. For example, when looking at risks for MRSA they would select MSSA controls, which is incorrect.  Unfortunately, many authors still select the wrong control group and unknowingly publish conditional odds-ratios.  I will discuss this more in a later post.

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.

Anthony Harris and I have also written extensively on the appropriate use and analysis of quasi-experimental studies looking at interventions to prevent hospital-acquired infections. In a trilogy of CID review articles, we reviewed the optimal quasi-experimental designs (2004), the frequency of each design's use (2005) and appropriate statistical analysis of time-series data (2007). If you're planning on doing a non-randomized study of any infection prevention intervention, please look these papers over. Following the optimal methods outlined in these reviews will improve your studies and also increase the chances that your intervention study's results will make the grade and be included in future systematic reviews, such as Cochrane reviews.

Image Reference: DA Grimes, Lancet 2002;359:57-61

Friday, March 16, 2012

The post-antibiotic era isn’t coming soon. It is already here.


A speech Margaret Chan gave in Copenhagen recently is now attracting media attention. One semantic point—we should stop talking about the post-antibiotic era as if it were in the future. For the ICU patient dying of pan-resistant Pseudomonas pneumonia, or the person removed from a transplant list due to pan-resistant Acinetobacter infection, the post-antibiotic era is now!

As you read Dr. Chan’s address, which focuses on EU efforts, think about how our fragmented healthcare system and dysfunctional political environment affect efforts to prevent and control resistance. Are you interested in tracking how antibiotics are used in the United States? Sorry, we don’t have those data. Would it be useful to expand our surveillance for antimicrobial resistance to a truly nationwide program? Nah, that won’t happen—CDC and public health budget cuts may make it impossible to sustain even the existing Emerging Infections Program. Would you like to see more funding of research to determine which prevention approaches are most effective, and which antibiotic treatments provide the best outcomes (and which are unnecessary)? Not likely, in the current climate.

In combination with underfunding of prevention, the current political hysteria over the Affordable Care Act is likely to have a major negative impact on antimicrobial stewardship and antimicrobial resistance control. The current opposition narrative—where any suggestion that “less is more” is a hidden agenda to install death panels to kill us all (“no antibiotics for you!”)—is anathema to good antimicrobial stewardship.

Wednesday, March 14, 2012

Stewardship, stewardship, and more stewardship!

That’s what you’ll find when you read the April issue of ICHE. The entire issue is dedicated to antimicrobial stewardship, and includes several excellent articles. So consider it your Spring Break reading.

There’s even an article from Eli’s old stomping ground, describing what happens when you take an effective antimicrobial stewardship program and flush it (spoiler alert: turns out to be a bad idea). Lest we forget, the Maryland group is still the only one to demonstrate, in a randomized controlled trial, the effectiveness of adding computerized clinical decision support for stewardship efforts. So go back and read that paper too, while you’re at it.

I’ll end with this quote from our friends Arjun Srinivasan and Neil Fishman, from the intro to the special issue:

There has perhaps never been a more critical juncture for antimicrobial stewardship. There is growing interest from key stakeholders—clinicians, healthcare administrators, and policy makers—and a growing body of evidence demonstrating the benefits of stewardship. We now need to harness the interest and the science to move toward making stewardship programs an integral part of all healthcare facilities. Education and messaging will play an important role. For too long, our message on the benefits of stewardship has been too narrowly focused on reducing costs and potentially reducing antibiotic resistance. The former is not compelling to most clinicians, and the latter, while generally accepted, has been difficult to demonstrate clearly since the emergence and spread of resistance is so complicated and multifactorial. Moving forward, we need to emphasize that antibiotic stewardship is, fundamentally, a critical patient safety and public health issue for all healthcare settings that can improve the quality of care.

Photo: Alexander Fleming, from Wikimedia Commons

Monday, March 12, 2012

I'm madder than a giraffe with a sore throat...

…over the CDC budget, which Eli blogged about last week. As their budget gets cut further and further, the CDC leans more heavily on the Prevention and Public Health Fund (“Prevention Fund”) to pay for core functions. The problem is that the Prevention Fund was originally designed to fund new initiatives, not to fill in for ill-advised core budget cuts. And since the fund was established as part of the Affordable Care Act, it has now become a political target (and was already cut drastically as part of the payroll tax cut extension and Medicare “doc fix” deal). If you require further evidence of the tenuous status of the Prevention Fund, know that it has been termed “an Obamacare slush fund” by the GOP (note to whoever came up with that genius terminology: you are a colossal ***).

Ezra Klein had a great post last month about why prevention funding is so vulnerable in the current climate. In it he quoted Rick Mayes from the University of Richmond, on the “prevention paradox”:

“If public health measures are effective, the problems they are aimed at are often solved or never even materialize, thereby making them virtually invisible.

Few individuals have personal interactions with or know what epidemiologists, health program coordinators, virology trainers, and outreach specialists do. When individuals are spared from a disease because the air in their office building is clean, it is not immediately clear whom to thank or if thanks are even necessary. As a consequence, public health professionals, programs, and policies are largely invisible to the public and taken for granted.”

I agree with this, but I think the issue is even larger, and more depressing. The statement above assumes that if people were just informed of the consequences of not supporting prevention efforts, they would act differently. I don’t think so. I’m hearing more political candidates question the basic social contract, the very assumption that government has a legitimate role in providing for the common good (and that we all have an obligation to pay for it). I encourage you to listen to this podcast, entitled, “What Kind of Country”, which details some trade-offs that local governments are making when money runs out and citizens are no longer interested in paying to provide for the common good. I was particularly struck by the story of individual citizens refusing a small tax increase to keep all the streetlights on in their town, but willing to pay $300 out of pocket to keep the lights near their own house burning.

Saturday, March 10, 2012

Submit your work to IDWeek!

Although the abstract deadline for IDWeek is still 2 months away, it is not too early to decide what work you wish to submit for presentation in San Diego in October. The abstract submission site is open until May 11, 2012 for regular submissions and until August 10, 2012 for late breakers.

Thursday, March 8, 2012

(More) Other Advice to Young Epidemiologists

1) Don't call anyone an idiot.
2) Question subjects carefully.



For "other advice" see ICHE 2006

Wednesday, March 7, 2012

How to have your influenza vaccine and get the flu too!

We just had our first confirmed case of influenza in Lake Wobegon, out here on the edge of the prairie. At the VA at least.  Helen Branswell of the Canadian Press has a great article in the Winnipeg Free Press today exploring the reasons why we might be having such a late and mild flu season.  Possible reasons include a mild winter and perhaps high vaccine uptake.

Branswell quotes one of our favorite Canadian's Allison McGeer who said "there's lots of evidence that it's not as simple as temperature. People have been looking for temperature and humidity indications for a long time — and there may well be some contribution — but if it is, it's subtle and complex. It's very clear that it's not just having a milder than usual winter that makes a difference."  The article also mentions that vaccination rates in Canada and the United States are around 35-40%, which should not be high enough to explain the magnitude of annual influenza epidemics. Of course vaccination rates are only relevant if the vaccine is effective.

In the most recent issue of Archives of Internal Medicine, Kenny Wong and colleagues from the University of Toronto studied the effectiveness of influenza vaccination in a large cohort of community-dwelling Ontario residents over 65yo. Using administrative data from 2000 to 2009 and controlling for selection bias using an instrumental variable approach, they report minimal effectiveness in reducing all-cause mortality. Looking at a composite outcome of mortality plus admissions for pneumonia, they did find vaccine to be protective. For an excellent review of this paper, prior studies and the use of instrumental variables, see this most excellent post by Robert Roos over at CIDRAP. The summary of all of this is: with current vaccines, those over 65 can have their shot and get the flu too.

Sources:
1) Wong K, et al. Arch Intern Med. 27 Feb 2012
2) Branswell H, Winnipeg Free Press. 6 Mar 2012
3) Roos R, CIDRAP. 1 Mar 2012

Tuesday, March 6, 2012

Turn that Code Brown upside down!

Because it’s Clostridium difficile prevention day! The CDC just issued a new Vital Signs report on C. difficile (MMWR details here), Cliff “C-diff” McDonald has a blog post up at Safe Healthcare, a podcast can be found here, and an updated CDC webpage on C. difficile is here.

The CDC media telebriefing took place at noon ET today, and we are already beginning to see the news media responding. One main message can be illustrated via Figure 1 from the MMWR report, below. The rest you can read for yourself.

British Olympics Handshake Kerfuffle

Dr. Ian McCurdie, the British Olympic Association's chief medical officer warned his athletes to avoid handshakes this summer or they might pick up germs, according to a recent AP story. In response the Department of Health said: "It goes without saying that we should all wash our hands regularly to keep them clean and prevent spreading bugs, but there's no reason why people shouldn't shake hands at the Olympics." The best take on this probably came via Twitter when Olympic champion rower Zac Purchase said it's a "bit pointless unless u r going to run around with disinfectant 4 every surface you come into contact with."

This is serious business.  In 2008, Great Britain came in 4th in overall medal count, a scant 26 medals behind Russia.  From what I can tell, the only thing that held them back was a spike in transient infections!

We've posted on this sort of thing before where a study last year found the risk was 0.019 bacterial pathogens acquired per handshake during a commencement; although, it's viruses that we most worry about. Of course, if you don't want to shake someone's hand there are other greeting options:



3/7 Update:  Another nice opinion is available here, and the ban has officially been lifted.

Monday, March 5, 2012

Religion vs infection control: issue #6


Here's a new and very sad case to add to our series on the intersection of religion and infection control. A few days ago, The New York Daily News reported that an infant died in a Brooklyn hospital due to disseminated herpes simplex virus type I infection. The virus was transmitted to the baby via a practice, metzitzah b'peh, performed by some mohels following circumcision whereby the mohel uses his mouth to suck blood from the wound. In a related piece, a rabbi and mohel in the Broward-Palm Beach New Times blog, provides details on how the procedure can be performed safely while still fulfilling Talmudic requirements. Several other cases of neonatal herpes infection (see full text paper from Pediatrics here) and at least one death have been previously reported. Additional information from the New York City Health Department can be viewed here.

Graphic:  The ceremony of Brit-Milah by Herman Gold.

Can you tell a hospital is safe by its "broken windows"?

This past weekend there were many discussions of James Q. Wilson's "broken windows" theory. Dr. Wilson, unfortunately, passed away this past week. The theory and research suggest that perception of a safe neighborhood prevents crime. If people feel they're in a safe place, they are less likely to commit a crime. If, however, they feel the neighborhood is unsafe or crime-ridden, they're more likely to commit crime. Thus, under this theory, police forces should arrest and prosecute even the smallest crimes, such as graffiti, and cities should quickly repair broken windows.

I lived in Rudy Giuliani's New York City during the implementation of this strategy, but I'm not here to defend his law enforcement policies one way or another, since I'm not an expert. Crime did fall, but it might have been for other reasons.  What I'm more interested in is if there could be an analogous theory in hospitals?  Is there a safe hospital theory?  It made me wonder if clinicians in safer or cleaner hospitals are more apt to practice hand hygiene or have higher compliance with CLABSI checklists.

I'm not aware of much data in this regard.  Two of the better analyses were done by Pat Stone's group at Columbia (I was a co-author). Looking at data from 415 ICUs in 250 hospitals they found that there was no convincing evidence of a cross-over effect between CLABSI and VAP; that is compliance with the CALBSI Bundle elements was never associated with a decrease in VAP rates.  In a separate paper, they found that compliance with the VAP bundle did not lower CLABSI rates. So for at least two device infections, there appears to be no such thing as a safe hospital. Lankford et al. in EID (2003) hypothesized that hand hygiene would increase after construction of a shiny new hospital. It actually decreased from 53% to 23%.  Hopefully Mike and Dan can add to this list of studies.

There has been a lot more research on what makes a quality hospital outside of infection prevention.  Twenty years ago, there was an important study in Medical Care that looked at disease-specific mortality in acute myocardial infarction, congestive heart failure, pneumonia, stroke, obstructive lung disease, or gastrointestinal hemorrhage in 30 hospitals. They found little correlation between disease-specific mortality rates within each hospital. So, MI mortality was not correlated with CHF mortality, even if they were likely to be treated by the same physicians and nurses. If mortality isn't a quality indicator, one wonders if other quality indicators have any relevance.

And what is a post without a non-scientific anecdote? Several years ago, when I was the hospital epidemiologist at a large hospital in Baltimore, we had high rates of MDR-Acinetobacter infections. This led our group to conduct a pilot study looking at the impact of universal gown and gloves in ICU-settings. At the time a new Chief Medical Officer, who happened to be a pulmonary-critical care specialist, started attending in our ICUs. He was struck at the level of gown/glove compliance that he saw and declared that he had never seen such a safe hospital. This actually meant something, since he had just moved from Barnes Jewish Hospital in St. Louis; home to one of my heroes, Vicki Fraser.  Were we really safer than BJH? I don't know, but the sight of all of those gowns and gloves did make it appear that we were really trying our best to be safe. Soon after, our CLABSI rates fell drastically, after a lot of effort sure, but the culture was changing. Maybe there is something in this theory that applies to hospitals after all? Too bad there appears to be no such thing as a "safe" hospital.


Sunday, March 4, 2012

CAUTI: The Rodney Dangerfield of HAIs

For several reasons (lower attributable mortality and cost, mostly), catheter-associated urinary tract infections (CAUTI) get far less respect or attention than VAP or CLABSI. However, the sheer number of CAUTIs provides a good reason to pay attention to their prevention. Fortunately, it’s not that complicated (here’s the SHEA compendium and HICPAC guidance).

The big message, of course, is “get the catheters out!” Which brings me to a recent study in Archives of Internal Medicine, reporting results from the statewide Keystone initiative to reduce urinary catheter use in Michigan hospitals. The good news is that the interventions (clinician education and daily assessment of catheter necessity during nursing rounds) were effective, resulting in an almost 30% reduction in catheter use in participating hospitals. The bad news is that even after the intervention, less than 60% of catheter use was for indications defined as “appropriate” based upon HICPAC guidelines. These guidelines aren’t all-inclusive as regards appropriate catheter use, but it seems clear that every hospital still has a lot of room for improvement here.

Friday, March 2, 2012

When did "CDC Funding" become an oxymoron?

A proposed $664-million cut in congressional funding may be in store for the CDC in FY2013. There appears to be some attempt to backfill the cuts with support from other sources including the Prevention and Public Health Fund.

Per a recent Nature-News article, the cuts would impact the CDC core budget and impact grants to "local, county and state public-health departments to monitor infectious diseases or track food-borne outbreaks." If these cuts stand, the CDC budget will have fallen by 20% since 2010.

Just last week, Trish Perl circulated an email query asking what key concerns we have in infection prevention over the next 2-3 years. Many were concerned about increased work demands for public reporting and mandates. Mike and Dan had several other concerns they will hopefully share with us in future posts. My main concern was the loss of the CDCs voice in the fight against antibiotic resistant bacteria as their funding is slowly cut. I guess it will be quickly and not slowly.

Source: Meredith Wadman in Nature 483, 19 (01 March 2012) doi:10.1038/483019a

Evidence-based Backlash: The Xigris eXample

Rich Savel, has a wonderful editorial in this month's issue of the American Journal of Critical Care (AJCC) discussing the importance and dangers of evidence-based medicine as currently practiced. He and co-author Cindy Munro use the rise and fall of Drotrecogin Alfa (Xigris, activated protein C) as an example for what can go wrong and why.

Rich Savel in the center
Their key conclusions:

1) "Though the results of a single, large RCT are important, they clearly are not sufficient for future agents to be rapidly integrated into national guidelines or consensus statements."

2) "Another important lesson is that pharmaceutical companies should stay as far removed as possible from development of guidelines promulgated by national medical societies. One of the most important things such a society has is its reputation, which it must be careful not to tarnish. Although this can often be a great challenge, it has become quite clear from the controversies surrounding APC that the relationship between pharmaceutical corporations on the one hand and academia and national medical societies on the other should be kept distinct and transparent."

3) and finally - “... the single most important lesson from the rise and fall of APC is that we should maintain skepticism: maintain it until the trial can be reproduced; maintain it in the face of trusted medical societies integrating recommendations for agents before sufficient evidence is presented; and maintain it until all potential conflicts of interest have been shared. EBM is not merely one way to practice; it is the only way. In addition to understanding all of the dynamic complexities and nuances of EBM, we must develop a healthy skepticism toward new research results and apply that approach liberally as the scientific method does its important job of confirming the validity of those results."

Full Disclosure: Rich and I were residents at NYH-Cornell back in the 1990s and we were also co-Assistant Chief Residents at Memorial Sloan Kettering under Kent Sepkowitz. Rich has gone on to great things as co-editor of the AJCC and medical directorship of the surgical intensive care unit at Montefiore Medical Center, Albert Einstein College of Medicine in NYC. Rich is also the editor and founder of the SCCM iCritical Care Podcast - which rocks.

Thursday, March 1, 2012

What is Sepkowitz saying about antibiotic resistance?

I give up. What am I supposed to do to protect my patients from his MDR-homeboys?

In his new Slate piece, Kent raps about resistant gonorrhea, MDRO-bogeyman and the Masters-of-the-Universe complex of antimicrobial stewardship. Last week I gave up washing my hands, but I'm not sure what I should do now. I think I'm supposed to give up.  Help me out here.

Source: Kent Sepkowitz, Slate, 1 March 2012

Preparing a Poster for APIC (or IDWeek)

With SHEA just around the corner in October, you're busily making your posters, right? (joke) Kendall Powell at NatureJobs.com has a nice post covering what makes a good (and not so good) poster presentation at a scientific meeting.

Tips range from the important mundane "Titles and headings should be in a sans-serif font, such as Helvetica. Other text should be in a serif font such as Times New Roman, with a minimum size of 22 points" to the important and you never see "Enlarge the best piece of data and place it squarely in the middle at eye level."

Worth a read.



image caption: Elaine Larson, CIRAR Director and Bevin Cohen, CIRAR Project Coordinator APIC Annual Conference, Ft. Lauderdale, FL, June 2009

Tell us your reckons...

We know hospital epi folk aren't on twitter or Google+. This blog is where you are and we love you for that. Now, there are only 3 of us but there are at least 17 of you (if you count our spouses), so we can't do it without you. Also, if you know what "it" is, please let us know that too. Good day and may your God go with you...


h/t ed yong