Wednesday, May 30, 2012

(Twinrix x 2) x 3 = (0.95) HBsAb+

I recently had a dentist referred to me for treatment of an infection and in reviewing her chart incidentally noted that her hepatitis B surface antibody was negative. In taking her history I learned that after receiving the hepatitis B vaccine series twice (6 doses), she still had a negative hepatitis B surface antibody, which indicates no protection against hepatitis B, a major occupational hazard for dentists.

To the rescue is this important study (full text here). In this study, 48 hepatitis B vaccine nonresponders were given double doses of Twinrix vaccine (combined hepatitis A + hepatitis B vaccine) at 0, 1 and 6 months. At the end of that vaccine series, 95% of the nonresponders developed protective levels of antibody against hepatitis B. This is a very cool finding for healthcare workers who are hepatitis B vaccine nonresponders.

The study isn't new. Dan reviewed it for Journal Watch several years ago (full text here), but I wasn't aware of it and neither were my partners, so I thought it would be important to highlight this paper.

When antibiograms mislead

Whether in our coat pocket or e-device, most of us carry an antibiogram whenever we are seeing patients. The antibiogram is meant to help guide empiric antimicrobial therapy, and usually provides “percent susceptible” for most common bug/drug combinations. However, too many antibiogram users do not understand the limitations of using these aggregate data to treat individual patients. Most understand that hospital-wide antibiograms aren’t applicable across every unit, and formulating unit-specific antibiograms is now common practice.

A more concerning issue, though, is that current antibiogram guidelines recommend including only the first isolate of a given species from each patient, excluding subsequent isolates. While this approach prevents a single patient from having undue influence on the aggregate data, it has the effect of ignoring the risk of emerging resistance during prolonged hospitalizations. In this month’s issue of ICHE, Duke investigators demonstrate the consequences that this approach may have. Read this study for yourself, but the short version: antibiograms lose their predictive utility for Pseudomonas aeruginosa susceptibility by about day 10 of hospitalization for most important anti-pseudomonal agents.

Tuesday, May 29, 2012

NIH Embraces Hand Hygiene - VIDEO!!!

NIH Director Dr. Francis Collins sings "It's So Easy to Clean Your Hands"... and look out for David Henderson's back-up vocals - talent! All done to celebrate the NIH Clinical Center's first Hand-Hygiene Awareness Day.



h/t Monica Páez

Monday, May 28, 2012

Weekend wrap-up

I'm writing this from my porch on a warm Richmond evening, wrapping up a great holiday weekend with my wife. No clinical work for me this weekend, but did a lot of things--detailed my car, made a big batch of gazpacho, worked in the garden, played the piano, tried to figure out what to do about the yellow jacket nest in the yard, and went to the gym. You know, things that normal people do. It was a refreshing break from the hassles of arguing with insurance companies about why treating MAC pulmonary infection requires more than 5 days of clarithromycin, documenting,  documenting, and more documenting every fricking thing we do, and playing the regulatory compliance game (a game where no one tells you the rules but consultants remind you that what you did do was wrong).

To make the weekend even better, I received the following email from a patient with a 5-month history of relapsing C. difficile infection that I did a fecal transplant on several weeks ago (she graciously allowed me to share it):
Wanted to let you know that it has been a couple of weeks since the transplant and I am back to my old self. My energy is back and so far I'm feeling terrific. Thank you so much for everything you and your staff did to help me. Everyone was so friendly and competent. I want to especially thank your nurse who did a great job in getting me to relax during the (nasogastric) intubation, which was the most uncomfortable part. It feels wonderful not to have to take any more antibiotics. I wish for you and your staff the very best and I hope that this procedure continues to help more and more people who have been going through this debilitating disease. Words cannot express adequately how grateful I am.
Emails like this one serve as a great reminder of why I went to medical school. And it helps to put the bucket of broken into perspective.

As I sit here watching a great blue heron fly over the James River, I can only think that tonight it's all good. Tomorrow, back to the grind!

Graphic:  Anna DeStefano

Saturday, May 26, 2012

Postmodern infection prevention

My bad! A few weeks ago I was handing out kudos to APIC for removing all the "getting to zero" propaganda from their website. Was I an idiot or what?! Now zero has become APIC's new vision--Healthcare without infection. All of us would like healthcare without infection. All of us would like automobiles without vehicular accidents, too. But most intelligent human beings who have ever driven a car know that we'll never eliminate automobile accidents no matter how many safety features the auto industry designs. Importantly, we've learned that there are many things we can do to make driving safer. The same holds for healthcare.

I think the zero kool-aid that APIC keeps drinking is really part of post-modernism, the philosophical paradigm that holds there is no absolute truth. Postmodernism is inherently anti-science. David Gorski, a physician who blogs at Science-based Medicine, writes:

"To the post-modernist “scientific medicine is no more valid a construct to describe reality than that of the shaman who invokes incantations and prayers to heal, the homeopath who postulates “healing mechanisms” that blatantly contradict everything we know about multiple areas of science, or reiki practitioners who think they can redirect “life energy” for therapeutic effect. In the postmodernist realm all are equally valid, as there is no solid reason to make distinctions between these competing “narratives” and the “narrative” of scientific or evidence-based medicine."
Stephen Colbert talks about truthiness,"truths that a person claims to know intuitively "from the gut" in that it "feels right" without regard to evidence, logic, intellectual examination, or facts." According to Colbert, “It used to be, everyone was entitled to their own opinion, but not their own facts. But that's not the case anymore. Facts matter not at all. Perception is everything. It's certainty.”

A few years ago, a colleague, also a hospital epidemiologist at an academic medical center, sent me an email that encapsulates the effect of postmoderism on our field. He wrote:
“I used to think that the increased attention on HAIs would be a really good thing, despite the hassles. But I sense that the tide has turned strongly and decisively against the academic, ID-trained hospital epidemiologist. No one defers to that training or expertise anymore–they bow down instead to Toyota models and non-ID trained, self-styled patient safety gurus who preach buzzwords. At my hospital we now report to hospital administration only through someone who spent most of his career in the automotive industry. He's a nice guy and all, but come on, nobody at the table when the “hospital leadership group” discusses infection data has any ID or infection control training!”
If we could be magically transported back a half century with the corpus of evidence about healthcare associated infections that exists today, it might be possible to come close to eliminating HAIs in the hospital of 1962. But advances in medicine continue to make patients more immunosuppressed and devices have become increasingly more invasive. We continue to bypass every one of the body's natural barriers to infection. This is why, as I have said previously, I have yet to meet an infectious diseases physician who believes that HAIs can be eliminated. During my travels I have found that most infection preventionists agree. This leads me to believe that there is some disconnect between APIC leadership and the IPs in the trenches. And it's a good thing I'm not a cynical person! If I were, I might think that APIC's vision would be a great way for the organization to "partner" with industry to prevent infections through some good old fashioned quid pro quo.

I decided when I was a fourth-year medical student that I wanted to be a hospital epidemiologist. I very much wanted to spend my career studying the problem of HAIs and designing ways to reduce them. I still find it fascinating over two decades later. I would love to see the day when there are no HAIs. But I live in the reality-based community that embraces modernism, a place where science is the tool to explain what we observe in the world. So I'll freely admit that I believe in microbiology, epidemiology, vaccines, climate change, and anything else that valid evidence reveals to be true. I also believe that APIC is unfortunately spinning ever further into a parallel, postmodern, anti-science, truthy universe.  

Photos: Institute for Science in Medicine;  BWOG

Friday, May 25, 2012

Outbreak at the rodeo

Infectious diseases continue to plague us and have numerous impacts on society. You probably didn't know that there's currently a horse herpes outbreak in Utah, which is forcing rodeo queens to demonstrate their skills using stick ponies. Click here to read the story and watch the video.

Have a great holiday weekend!

Hat tip:  John Boothby                Photo: KSL

HIV PEP: The sooner, the better

There's a disturbing report in the June issue of Infection Control and Hospital Epidemiology which details transmission of HIV to a healthcare worker following an occupational injury. The provider was placing a central line in a patient with AIDS and cryptococcal meningitis and was stuck with a 25 gauge needle used in the procedure. The patient was HAART-naive and the HCW was HIV negative at the time of the injury. The initial post-exposure prophylaxis (PEP) regimen (combivir + kaletra) provided to the HCW is a CDC-recommended regimen. This was changed to truvada + atazanavir (also CDC recommended) due to diarrhea on the 10th day after exposure. A total of 4 weeks of post-exposure prophylaxis was administered. Sixty days following exposure the HCW developed fever, fatigue and myalgias and was found to be infected with HIV.

Since the introduction of HAART PEP, HIV seroconversion in HCWs has nearly disappeared despite the large number of sharps injuries that occur. Importantly, the transmitted virus had no resistance to any of the antivirals used for prophylaxis. The only potential problem described in the report was that the first dose of PEP was administered 18 hours after the exposure occurred, and one is left to wonder if infection would have occurred if the first dose had been administered sooner. Our goal is to have the first PEP dose on board within one hour of exposure.

Photo: A Medical Resident's Journey

Thursday, May 24, 2012

Value versus return on investment

The Viewpoint piece in today’s JAMA is a helpful reminder to step back and ask why we often apply a different standard to prevention programs (will they save more money than they cost?) than we do to other healthcare expenditures. I’ll paste an excerpt below, but you can read the whole thing here.

“Clinicians and policy makers should not apply one standard when tacitly continuing the status quo and a different standard when evaluating innovative programs that might be implemented. It certainly does not make sense to use one criterion—Are there clinical benefits?—for coverage decisions for treatments and a different criterion—Are health care savings greater than program costs?—for preventive services..”

Wednesday, May 23, 2012

More antibiotics NOT more better in sepsis

There is a meme in antibiotic therapy for all infectious disease clinical syndromes that earlier and more antibiotics lead to lower mortality. I'm not sure that this meme is supported by data from good studies, but it has been so effectively spread through the establishment that its very existence goes unnoticed (check this abstract's first sentence). I think this unproven belief threatens effective antimicrobial stewardship and is partially responsible for the emergence of antimicrobial resistant organisms, but I digress...

Published online in JAMA this week is a randomized trial of dual antibiotic vs monotherapy in sepsis funded through the German Sepsis Research Network (SepNet). The 2.5 year study in 44 German ICUs compared meropenem monotherapy (n=298) with meropenem+moxifloxacin (n=278) in patients with sepsis or septic shock. Patients were treated for 7 to 14 days or until discharge or death and duration was informed by a procalcitonin-guided treatment protocol on study days 7 and 10. The primary outcome was mean of daily total Sequential Organ Failure Assessment (SOFA) scores over 14-days with similar scores in both monotherapy (7.9 points) and dual therapy (8.3 points) patients, p=0.36. 28-day mortality was 22% in the mero and 24% in mero+moxi patients (p=0.58) and 90-day mortality was 32% in the mero and 35% in the mero+moxi patients (p=0.43).

Groups were similar and infections were predominately pneumonia, intra-abdominal and GU. Blood cultures were positive in 33% of patients with Escherichia coli and MSSA being the most commonly isolated, while 18 had MRSA from any source. 100% of cultures tested were susceptible to the mero+moxi combination while 94% of specimens were susceptible to meropenem monotherapy.

This is an important study and one that should make us question current empiric therapy dogma. However, it doesn't answer the question whether antibiotics overall made a difference and whether other therapeutic options including source control might be more important.  It's nice to see clinical ID slowly emerge into the modern evidence-based medicine era even if so few studies are completed in the US.

image source: http://abacaxihortela.blogspot.com/2011/09/only-1.html

Tuesday, May 22, 2012

The Yang to Handwashing's Yin: Drying Your Hands

Joe Smith, Portland (Oregon) lawyer and tree savior tells us how a simple two-step trick can save 571,230,000 pounds of paper towels every year. Want to know the secret? Spend 4:28 with Joe and find out.

Monday, May 21, 2012

Another nosocomial hepatitis C outbreak


The Sydney Morning Herald today reported on the trial of an Australian anesthesiologist who has been implicated in an outbreak of hepatitis C. The anesthesiologist was reportedly known to be infected with hepatitis C and was addicted to fentanyl. Allegedly, while working at a day surgery center, following self-injection of fentanyl, he would then use the same syringe to inject patients with drug that remained in the syringe. The outbreak appears to involve 56 patients.

Photo: eQuoteMD

Thursday, May 17, 2012

Antibiotics are dangerous


A study in this week’s NEJM is getting a lot of media attention, reporting that azithromycin use is associated with an increased risk for cardiovascular death--especially among those with underlying cardiac risk factors.  The increased risk found in this large retrospective cohort study (performed with a big ole’ Medicaid database) was relative to amoxicillin, and was no different than the risk of cardiovascular death among levofloxacin recipients. 

Now, we can quibble about the study design, and about the small absolute risk found (this NY Times article provides some sample quibbling), but to me the larger point to make (again) is this: ANTIBIOTICS ARE UNSAFE.  They can be lifesaving, to be sure, but they carry risks for all manner of adverse reactions, including life-threatening allergic reactions, organ failure, C. difficile disease, cardiovascular death, emergence of multiple drug resistance, etc., etc. 

I don’t prescribe chemotherapy for treatment of cancer. There are many reasons for this, not least of which is that I am not an oncologist, but one is certainly the widely acknowledged toxicity of chemotherapeutic agents. Somehow, though, antibiotics have developed a different reputation--as generally safe, well-tolerated, with few downsides. Why else would they be so widely prescribed to patients who don’t need them, or made available over-the-counter in some locales, or allowed to enter our food supply?  As John Bartlett points out in the Times piece:
“We use azithromycin for an awful lot of things, and we abuse it terribly,” Dr. Bartlett said. “It’s very convenient. Patients love it. ‘Give me the Z-Pak.’ For most of where we use it, probably the best option is not to give an antibiotic, quite frankly.”
Perhaps spurring stewardship efforts requires striking more fear into the hearts of antibiotic prescribers.  Those who understand the many downsides of antibiotic use will be much more parsimonious about their use.

Wednesday, May 16, 2012

The Changing Face of Transmission Prevention

Yesterday I gave a talk at a 3-day VA-sponsored conference titled: "Infection Prevention and Control in the 21st Century - It's Everybody's Business."  It was a well-attended conference in Dallas. Most of the talks were titled: "The changing face of..."  I focused my talk on how novel MRSA strains, mupirocin resistance and the increasing importance of Gram-negative bacteria will result in a shift toward horizontal infection-control interventions. Please note that the VA MRSA Initiative actually included 3 horizontal interventions (hand hygiene, culture change and support for an MRSA coordinator) and only one vertical intervention (surveillance swabs and isolation), so VA has made great strides in implementing horizontal infection-control interventions.

Just a reminder that Dan, Mike and I have posted many of our recent talks in a section called "Presentations" down a bit on the right-side column of our blog.


News flash: Patients don't like isolation precautions!

A new study in the May issue of Infection Control and Hospital Epidemiology compares HCAHPS survey responses between patients who were isolated during hospitalization and those who were not. HCAHPS is a patient satisfaction survey used by CMS as part of its value based purchasing program. The study involved survey results from over 8,000 patients at the Cleveland Clinic, a hospital with a superb reputation for customer service. Of the isolated patients, nearly three-quarters were in contact precautions (of note, the authors point out that patients are not routinely isolated for MRSA or VRE at their hospital). Findings of note included:

  • Isolated patients were more likely to report problems with physician communication (treatment with respect and courtesy, careful listening, understandable explanations)
  • Isolated patients less commonly reported obtaining timely help after pressing the call button and less help with toileting
  • Isolated patients more commonly reported that their room was not kept clean
  • Isolated patients were less likely to recommend the hospital to friends and family
It's worth repeating that isolation is the only intervention in medical care in which the person receiving the intervention bears all the burden and accrues none of the benefit. In hospitals where compliance with hand hygiene is high, it's time to re-evaluate the incremental benefit of contact precautions on transmission of multidrug resistant organisms.

Graphic: TakeForm.net

Monday, May 14, 2012

Myopic consequences

The May issue of American Journal of Infection Control has a survey of infection prevention programs in US hospitals assessing the impact of the CMS policy to restrict payment for hospital-acquired central line associated bloodstream infections (CLABSI), catheter associated UTI (CAUTI), and selected surgical site infections. Five hundred hospitals were randomly selected to participate and the response was 64%.

While the survey contained some good news, primarily that hospitals were making efforts to get urinary and central venous catheters removed more quickly, 3 disturbing findings were uncovered:

  • 32% of respondents reported a shift in resources to address the policy, as only 15% of hospitals increased resources to infection prevention programs to meet the mandate. While not directly addressed in this paper, the implication is that hospitals stopped performing surveillance for certain infections in order to perform surveillance for CAUTI (more on this below).
  • 27% reported that in response to the policy it has become routine practice to obtain urine cultures on patients admitted with urinary catheters in order to determine whether an infection was present on admission
  • 13% reported that it has become routine practice to obtain blood cultures on patients admitted with central venous catheters
Obtaining cultures on patients without signs or symptoms of infection is a terrible practice. Any positive results are extremely likely to be contaminants or colonizers, yet it is likely that a sizable fraction of these patients may receive unwarranted antibiotic therapy. This increases the cost of care, adds to the problem of antibiotic resistance, and increases the risk for C. difficile infection.

A companion paper in Medical Care Research and Review by some of the same authors is a qualitative study using semi-structured interviews with 36 infection preventionists to assess the impact of the Medicare policy. In addition to the issues noted in the survey, a few other unintended consequences emerged:
  • Providers intentionally not documenting infections in the medical record
  • Surgeons refusing to operate on patients at high risk of infection
  • IPs were concerned that in order to meet the mandate to perform surveillance for CAUTIs, they stopped surveillance for infections that were deemed to be clinically more important in their hospitals

To those of us who work in the field of infection prevention, none of this is surprising. In fact, we predicted all of these things would happen. It doesn't take a lot of imagination to think through a proposed mandate to envision adverse unintended consequences.

Graphic:  Pie and Coffee

Sunday, May 13, 2012

Epidemiological surveillance testing is a waste

Only last month, we posted on the Washington state pertussis outbreak. Back then, there were 640 reported cases through March.  A month later there are 1284 total cases, up from 128 the prior year.  To me, these seem like important data. For one, we've used them to sound the alarm over low vaccination rates.  Now an article in today's NY Times highlights the impact that state budget woes have had on the public health infrastructure and how this has blunted the epidemic response.

Skagit County's (pop: 117,000) top medical officer, ER doc Dr. Howard Leibrand, has some choice words for pertussis testing, which I've pasted below:

If the signs are there, he said — especially a persistent, deep cough and indication of contact with a confirmed victim — doctors should simply treat patients with antibiotics. The pertussis test can cost up to $400 and delay treatment by days. About 14.6 percent of Skagit County residents have no health insurance, according to a state study conducted last year, up from 11.6 percent in 2008. 

“There has been half a million dollars spent on testing in this county,” Dr. Leibrand said late last week. “Do you know how much vaccination you can buy for half a million dollars?” And testing, he added, benefits only the epidemiologists, not the patients. “It’s an outrageous way to spend your health care dollar.” 

Since antibiotic overuse has no cost or downsides from a public health perspective and we don't need to understand the scope of the epidemic, this is probably cool.

Image source: www.healthheritageresearch.com

Friday, May 11, 2012

MRSA MRSA MRSA!

Pronounced mar-cia.  "Everytime MRSA turns around, they hand it a blue ribbon or something." There's an awesome collection of microbiology related schwag for sale at Etsy in a collection curated by Wendy Joy.

Some stuff not to miss? The petri dish soap with natural honey scent streaked with E coli, the MRSA MRSA MRSA button and the sweet B. anthracis plush doll.  It's truly a great time to be alive! or at least it's great that it's Friday.

h/t @artologica
 

Thursday, May 10, 2012

Are you pro procalcitonin?

Clinicians over prescribe antibiotics. I spent several years exploring the risk-averse nature of physicians (specifically ID physicians) when it comes to avoiding treatment failure in diabetic foot ulcer, community-acquired pneumonia (CAP), and CVC bacteremia. Using binary choice contingent-valuation analysis our group determined that ID docs were very risk averse. For example, three of 34 ID physicians found a failure rate of 1% in CAP to be unacceptably high. So how do we acknowledge the risk-averse nature of clinicians, while at the same time safely improving antimicrobial stewardship through reducing over-prescription or shortening duration of therapy?

One possible and much heralded solution was going to be improved diagnostic microbiological tests, such as PNA FISH, which can rapidly detect clinically important (ie you need to alter therapy) pathogens, such as MRSA. These require waiting for positive blood cultures and haven't yet fully caught on, for whatever reason.  Importantly, these micro tests can't tell you if the patient is infected vs. colonized or what clinical syndrome they might have, such as pneumonia. Even a chest xray can't tell you if your patient has pneumonia.  That's why I was cautiously hopeful as I read a meta-analysis by Philipp Schuetz et al. of procalcitonin in directing antibiotic initiation and duration in acute respiratory infection, published online May 9th in CID.

Procalcitonin has gotten a lot of attention recently since it's been found that levels are high in severe bacterial infections but lower in viral or non-specific illnesses. Thus, algorithms that include procalcitonin cut-offs might help target initiation and withdrawal of antibiotic therapy without impacting clinical outcomes. To verify this claim, the authors reviewed 14 clinical trials with a total of 4221 patients to determine mortality, treatment failure and total antibiotic exposure in patients treated under procalcitonin-guided algorithms versus standard therapy. Mortality was similar in both groups (OR 0.94, 95% CI [0.71-1.23]) and treatment failure was slightly lower with procalcitonin (OR 0.82 [0.71-0.97]. Both of these were despite relatively poor-adherence in some of the studies. Importantly, total antibiotic exposure was decreased when using procalcitonin containing algorithms with a statistically significant reduction of 3.47 days. However, sample size was low when limited to ICU patients, so further studies are needed there.

These results do suggest that procalcitonin-containing antibiotic treatment algorithms may have an important role in respiratory tract infection therapy, particularly from a public-health, antibiotic resistance standpoint.  It remains to be seen if algorithms with limited clinical benefit for the individual patient but large potential benefits in terms of stewardship and public health will ever be widely adopted. Physicians are still risk averse, after all. Fingers crossed.

Source: Schuetz P. et al Clin Infect Dis 2012 (online May 9, 2012)

Image source: July 2009, Clinical Laboratory News

Wednesday, May 9, 2012

Hygiene rules

The June issue of the Journal of Infectious Diseases has an investigation of a norovirus outbreak among a soccer team (free full text here). The index case experienced nausea and vomiting in a hotel bathroom. The other cases had no contact with the index case or the bathroom after she became symptomatic. However, a reusable grocery bag with packaged cookies, chips and grapes was stored in the bathroom while the index case was ill. Even though the index case had no physical contact with the bag or its contents, it nonetheless became contaminated with norovirus, presumably via aerosolization of the virus during vomiting or defecation or via flushing of the toilet.While some media reports focused on the reusable aspect of the grocery bag, it seems likely that a disposable grocery bag would have become contaminated as well. The moral of the story is a simple one: don't store food in the bathroom!

Photo: Colorado Restaurant Consulting

Monday, May 7, 2012

Dawn of the age of untreatable infections? NDM-1 in India

"There is a tsunami that’s going to happen in the next year or two when antibiotic resistance explodes" - Abdul Ghafur, an infectious diseases physician in Chennai

Jason Gale and Adi Narayan have a feature article in this June's Bloomberg Markets discussing the rise of NDM-1 in India.  It's well researched and organized and does a nice job highlighting the human tragedy that's in our midst. There are quotes from Bob Moellering, Donald Low, Tim Walsh, Lindsay Grayson, David Livermore, Keith Klugman, and several clinicians and scientists in India that have been directly involved in NDM-1 discovery and treatment including Chennai microbiologist Karthikeyan Kumarasamy, who helped discover NDM-1.  Overall, this is a great resource for the intro to any NDM-1 or Gram-negative resistance talk.

I agree with CDC's Tom Frieden when he says that "we need to have good surveillance and ... we need to have good antibiotic stewardship," but I think we really need more than that. The article finishes with a quote by David Livermore who says "“Combine sophisticated medicine, poor sanitation and heavy antibiotic usage, and you have a rocket fuel to drive the accumulation of resistance...That surely is what India has created.”

Sure NDM-1 is in India but the problem of Gram-negative resistance is a much larger, non-border controlled, issue. Wasn't KPC first detected in North Carolina?  If we point (and then focus on) fingers, we miss the larger picture - Bruce Lee's Enter the Dragon? We need large investments in antibacterial discovery and infection prevention research and we need to build back up our public health infrastructure in the US. We're in this together.



h/t Jan Kluytmans


Addendum: I was concerned that Gale's well-written article would be used to point fingers and not pressure people to find solutions.  It seems that the first tweets from Bloomberg Markets are playing on fear and trying to scare people away from medical tourism in India.  It's too bad that articles like this can't be used to make a case for a coordinated response to the MDR-bacterial threat we face. I hope further discussion of this article takes a more long-term view.

Addendum #2: Now this editorial by the Bloomberg Editors is more like it. Although they still seem to miss that emergence is not limited to places like India with poor sanitation. KPC emerged in the US and MDR-Acinetobacter is alive and well on the East Coast.  If you haven't read it, Andrew Moore's 2003 story of the FDA's failure to approve magainin, is an amazing look into the barriers to antibacterial discovery.

Addendum #3: Listen to author Jason Gale discuss India's special place in the emergence of antibacterial resistance on PRI's The World. He says that "when you look at the drivers of drug resistance, India pretty much ticks every single box"

The blogging professor

There's an interesting article in the May 4 Chronicle of Higher Education on blogging in academia by Martin Weller, a professor of educational technology in the UK. He notes: "In terms of intellectual fulfillment, creativity, networking, impact, productivity, and overall benefit to my scholarly life, blogging wins hands down." I must agree with the good professor. He goes on to raise two important questions: Is blogging scholarship? (He argues yes!). And how do we recognize and reward academics who blog?

Weller notes that being an active blogger has reduced the number of journal articles he has published; however, blogging has increased his peer network, allowed him to stay up to date with knowledge in his field, increased research collaboration, and increased the number of invitations to give talks.

An additional advantage of blogging, I think, is the ability to address issues in real time. For policy issues, the journal format is often not timely enough and in some cases, too formal, to have the impact of a blog. And truth be told, it's a lot more fun to blog.


Graphic:  Hubspot

Saturday, May 5, 2012

Are contact precautions headed for extinction?

There's an interesting letter in the latest Clinical Infectious Diseases from Dan Morgan and Kathy Kirkland on contact precautions. They surveyed 34 infectious diseases physicians at a meet-the-professor session at the 2011 Infectious Diseases Society of America Meeting. Interestingly, only 38% believed that contact precautions prevent transmission of multidrug resistant organisms, and 74% felt that contact precautions may actually harm patients. The sample size of the survey was small and perhaps there's bias in that the participants had selected to attend a session on contact precautions, but the findings are intriguing. I suspect that some day in the future people will find photographs of healthcare workers wrapped in plastic as weird as we now find the plague doctor outfit.

Photo: Grim Reviews

Friday, May 4, 2012

Friday afternoon blogging from Deltaville

Greetings from Deltaville, Virginia.  I had hoped to be north of here by now, but apparently boat engines are fickle.  We hope to be off tomorrow, though, and after that my infrequent blogging will become even less frequent, at least until we reach Boston.  I enjoyed seeing fellow blogger Mike Edmond, and look forward to dinner this evening with the Wenzels.

Speaking of Friday afternoons, you know the old saw that hospital outbreaks are always reported or detected on Friday afternoons? Well, according to this study in AJIC, there might be some truth to it!  Here's hoping that your Friday afternoon isn't rudely interrupted with an outbreak, but beware: Monday's are no better.

Thursday, May 3, 2012

San Francisco Lab Worker Dies of Lab-acquired Meningococcus

There is a very sad report in today's San Jose Mercury News concerning a 25-year old associate at the San Francisco VA Medical Center's Northern California Institute for Research and Education (NCIRE) who'd been working on a vaccine for Neisseria meningitidis, serogroup B. The lab work is very important, since vaccines for most of the other major disease-causing serogroups (C, Y, W135, and A) have been developed and licensed in the US.

He apparently left work Friday evening without symptoms but two hours later felt feverish with a headache. By Saturday morning he had a rash and arrested in the car ride to the hospital. California-OSHA and CDC are investigating the case and have already confirmed that the strain he was infected with was the same serogroup B strain that the lab was studying.

Unfortunately, lab-acquired infections do occur with some frequency. The most memorable case for me was the report of a grad student in Singapore that was working on West Nile Virus yet became infected with SARS-CoV that had somehow contaminated his West Nile samples.

A few years ago (2009), Kamaljit Singh published a very nice review in CID covering microbiology lab-acquired infections.  Most of the data included in the review are old, with the included frequency data from 1976 and 1978.  However, I've pasted table 2 below, which highlights the relative risk of specific infections in lab workers compared to the general public.  After Brucella, N. meningitidis appears to be the second highest risk with a RR=40.8. The review also discusses the 16 cases reported between 1985 and 2001 and highlights the importance of tetravalent vaccine for all laboratory microbiologists. Sadly, that wouldn't have helped in this case.


Addendum: Updated report from SF Chronicle this morning (May 3) and local ABC affiliate reportName released and investigation uncovers lack of vaccination among workers (KQED). note: vaccination would have been ineffective in this case.