Friday, August 31, 2012

O Canada!

We've blogged many times about the problems associated with contact precautions, and recently we've begun to talk about scaling back on the infection control intervention that was touted as the be-all and end-all for the last two decades. Well, the Canadians are actually doing it! In this article from yesterday's Hamilton Spectator, we learn that many hospitals in Canada are no longer isolating patients with VRE, a pathogen described as "big and dumb." The head of infection control at Toronto's University Health Network says: “We think we can improve patient safety by actually stopping those specific VRE control measures.”

Are you up to your neck in chlorhexidine? Good!

When I have a little downtime, I like to think of new things to coat with chlorhexidine. If my colleagues and family members aren’t interested, I sometimes debate empty chairs about the merits of chlorhexidine. But regular readers already know how much we love chlorhexidine (despite my being well aware that this love could be fleeting).

As chlorhexidine (CHG) bathing becomes commonplace for ICU patients, it becomes increasingly important to understand exactly what we’re doing, and how we ought to do it. How long does CHG retain activity after a daily application? How much reduction in skin flora can be demonstrated? Are there commonly missed body sites that could lessen the impact of the intervention?

Mary Hayden’s group has a study in this month’s ICHE that begins to address some of these questions. Using a colorimetric indicator, they measured CHG concentrations at several time points between daily CHG application (using CHG cloths*, with no rinse). They found that CHG was usually detectable on the skin for the entire 24 hour period between bathing, but that concentrations dropped over time, with microbial counts inversely associated with CHG concentrations. As the figure below shows, the microbial density at inguinal sites was lower for CHG than either soap-and-water or non-medicated cloths (as might be expected).


Interestingly, the neck region was found to have lower CHG concentrations and higher colony counts, and upon direct observation was noted to receive less thorough cleansing. This could be important, particularly given its close proximity to tracheal/endotracheal tubes and central line insertion sites, and given that it is a body site frequently touched by care givers (while changing dressings, auscultating carotids, measuring CVP, etc., etc.).

*the COI statement points out that Sage, maker of CHG cloths, funded the MIC testing in this study, though the rest of the study was funded by CDC and NAIAD.

Dr. Ian Smith, 1922-2012

Farewell to Dr. Ian Maclean Smith, who died earlier this week in Iowa City. Dr. Smith was the founder and first director of the Division of Infectious Diseases at the University of Iowa, and was a faculty member here for over 40 years. He accomplished a great deal during his long career, some of which is summarized in this obituary. He retired the year I arrived at Iowa for ID fellowship training, so I only knew him as an emeritus professor and an occasional guide to the early Staphylococcus aureus literature. A few years ago, as I prepared a talk on the epidemiology of invasive S. aureus disease, I asked him for early (pre-antibiotic era) descriptions of the natural history of untreated S. aureus bacteremia. Shortly thereafter he showed up in my office with a bound volume of Lancet issues from 1960. The table below is from Ian’s 1960 publication in this volume, describing 338 cases of S. aureus bacteremia from 1936-1955, a time period that straddled the introduction of effective antimicrobials (pre-antibiotic era mortality was 90%).


While I was looking for an earlier photo of Ian, I also ran across an article from the Kingsport, Tennessee Daily News in April 1977 announcing that Ian had published two articles in the journal Geriatrics (yes, he was also a geriatrician). I had forgotten that his career at Iowa was interrupted by a stint at East Tennessee State University, a medical school he helped to establish and for which he was Chair of the Department of Medicine for two years. I was also pleased to see that the local papers saw fit to announce whenever faculty members published peer-reviewed papers. I’ll have to call our local Iowa City paper tomorrow morning...

Thanks, Ian, for your contributions to our field.

Thursday, August 30, 2012

The menace of antibiotics

Need another reason to be concerned about antibiotic overuse? Marty Blaser’s group just published a study in Nature about the impact of subtherapeutic antibiotics on the gut microbiome, metabolism and body composition of mice. Short version: antibiotics altered a myriad of things, including the gut microbiome, levels of metabolic hormones, and hepatic regulation of lipids. The end result? A fatter mouse.

We’ve known for some time that antibiotics in low doses promote the growth of animals, though it isn’t clear exactly how that works. These findings shed light on some potential mechanisms for weight gain associated with antibiotic exposure, and may have implications for the ongoing obesity epidemic.

Finally, another plug for IDWeek! I’m happy to point out that the senior author of this paper (Dr. Blaser) will be delivering a keynote address during the opening plenary, appropriately titled, “The Menace of Antibiotics”.

Photo credit: Wikipedia commons

Wednesday, August 29, 2012

Back from Canada

I recently returned from our annual trip to rural Quebec, a refreshing break from everything (including the internets!). Eli’s post below, about resource-intensive approaches to infection prevention that seem so attractive compared with the hard work of basic hand hygiene, reminded me of a conversation I had over dinner with a Canadian family friend. He asked for details about the current political debate over Medicare, and I explained how one side is interested in restructuring the program from a defined benefit plan to a defined contribution plan, thereby shifting the risk of future increased health costs from the government to the individual.

“What happens when you need care that you can’t afford?” he asked. I pointed out that medical illness and the associated costs were a common cause of personal bankruptcy in the United States. He sat in stunned silence for a few moments before ending our discussion with, “Well, that’s barbaric.”

Tuesday, August 28, 2012

The Rise of the MIC: Microbiological Industrial Complex

Mike "Alexander" Edmond
Note: This is the post I wanted to write regarding the NIH Clinical Center KPC outbreak last week until I noticed the posts and comments blaming the front line infection prevention staff.

"...we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex (MIC). The potential for the disastrous rise of misplaced power exists and will persist....As we peer into society's future, we-you and I, and our government-must avoid the impulse to live only for today, plundering, for our own ease and convenience, the precious resources of tomorrow. We cannot mortgage the material assets of our grandchildren without risking the loss also of their political and spiritual heritage." - President Eisenhower's Farewell Address January 17, 1961

In microbiology and clinical medicine, the MIC is the "lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism after overnight incubation."  I think it's time to recognize a new definition for MIC: the Microbiological Industrial Complex. The MIC encompasses the industry, associated lobbying efforts and government agencies that most benefit from the adoption of expensive and unproven testing and treatment. The MIC has had a tremendous impact on infection prevention practice through economic forces pushing for MRSA active surveillance mandates and perhaps mandatory flu vaccinations of health care workers. This MIC leads to the utilization of expensive (and largely unproven) interventions at great cost both economically and to the well-being of patients.  The more we spend on expensive sequencing, the less we can spend on actual prevention. Hand hygiene might not be sexy, but it does more to prevent the spread of resistant infections than any PCR test.

The latest evidence of the insidious rise of the MIC is the initial discussion surrounding the NIH Clinical Center KPC outbreak. So far, the only paper describing the outbreak covered the miracle of whole-genome sequencing and how it helped halt the outbreak, which it most certainly did not. The outbreak was halted using a grab bag of unproven and expensive interventions including the hiring of 9 hand hygiene "police" that monitored infection control practice 24-7.  Even NIH's Henry Masur speaking today on the Diane Rehm show said that sequencing "didn't conclusively prove" (what caused the outbreak).  Both he and Jule Segre suggested they only stepped up their infection control efforts because of the whole genome sequencing evidence, which is almost certainly not true. They would have used infection control escalation even without expensive testing. (listen to the Diane Rehm show segment here)

To understand the power of the MIC, you don't have to look further than a recent MSNBC report, which noted that the NIH sequencing cost $40,000 and suggested that this technique could spawn a $1 billion industry in the US alone. In discussing the whole genome technique, Dr. Segre was noted to say "When you have patients in your ICU who just paid $100,000 for an organ transplant,"...spending a few thousand dollars to protect them from an outbreak of deadly bacterial infections "doesn't seem like too much to ask."

It seems to me that since there is no evidence that whole genome identified the source of transmission here or elsewhere and even if it did it wouldn't have altered the course of the outbreak, we might better spend our infection control research and clinical dollars elsewhere.  Unfortunately, the MIC has more money and more NIH backing. The NIH has a National Human Genome Research Institute but it doesn't have a "National Infection Prevention Institute", for example.

Almost a year ago, Mike peered through his crystal ball and accurately predicted the future of KPC prevention in the US.  The NIH outbreak and report starts the countdown, and much like MRSA before it, the prevention efforts will be focused on expensive DNA surveillance efforts backed by large industry lobbying efforts and not investments in the research and expansion of basic and simple infection control efforts. It is easy to blame the healthcare worker for not washing their hands and look for a quick scientific panacea (DNA). Sadly, given that there have been only four high-quality hand hygiene improvement studies since 1980, we haven't provided clinicians with the proven tools to improve hand hygiene. If we continue to bow to the pressure of the MIC and avoid the harder tasks of infection prevention, we will be squandering our precious resources of tomorrow (antibiotics), as Eisenhower warned 50 years ago.

Further Reading:
(1) Maryn McKenna: The ‘NIH Superbug’: This Is Happening Every Day
(2) Ed Yong:  Genome detectives unravel spread of stealthy bacteria in a hospital
(3) Dr. Judy Stone: The NIH Superbug Story-A Missing Piece
(4) Mike the Mad Biologist: Some thoughts on the CRE Superbugs

Image source: wikimedia commons

Thursday, August 23, 2012

Not a failure, a lesson. The NIH KPC Outbreak

Mike posted about this yesterday and I'm sure we'll have more posts concerning the deadly KPC outbreak that occurred last year at the NIH Clinical Center. Since the whole report is behind a paywall (why is that??), I thought I'd describe the interventions taken to control the outbreak and also let you peruse the description of the 18 cases and 11 deaths (See table below).
The kitchen sink: the problem
and the current solution

Infection control measures used:
1) Index patient placed on enhanced contact isolation on admission.
2) All ICU patients during the outbreak were placed on universal enhanced contact precautions during their entire stay
3) A wall was built in the ICU, so that all KPC+ patients could be placed in a new six-bed unit
4) Infection control compliance monitors were hired (peak use was 9 monitors) who ensured that all healthcare workers entering the rooms practiced enhanced contact precautions and hand hygiene. Suboptimal monitors were fired
5) A private firm was hired to decontaminate the ICU and all KPC+ patient rooms using hydrogen peroxide vapor
6) Staff were cohorted so that staff did not care for both KPC+ and KPC negative patients
7) When the KPC was found in a sink, they tore out the plumbing
8) Active surveillance culturing using rectal and throat swabs was utilized

What an amazing effort by Tara Palmore and others at NIH. Why did it take so long to control the outbreak? It's not their fault. I was in a similar situation with an acinetobacter outbreak in 2002. What I faced in 2002 and what Dr. Palmore faced last year is that there is almost no science behind infection prevention interventions. We literally don't know what works or where in works. What this outbreak demonstrates is what happens when you make little investment in infection control science in decades. We don't know how to prevent these outbreaks, so we throw the kitchen sink (literally in this case) at them hoping something works.

Not every hospital can afford to undertake all of the expensive construction and staffing interventions that the NIH did, especially since it isn't clear what works and what doesn't. Unless we make serious efforts in understanding the science behind hand hygiene compliance improvement, optimal use of contact isolation, environmental cleaning and other "unstudied" areas, this scene will continue to be repeated over and over again. These outbreaks are happening every day in the US and patients are dying (see below). We need science in infection prevention just as much as we need novel antibiotics.  The lesson needs to be that we fund CDC and other agencies to direct the infection prevention studies necessary to prevent and terminate these terrible outbreaks.

The wrong lesson is to blame frontline infection prevention staff for fighting an outbreak with one hand behind their back and not being successful. We need to stop blaming clinicians and start funding the science to assist our infection prevention efforts.  If we won't have novel antibiotics for 10-20 years, we better start getting serious about infection prevention.


Wednesday, August 22, 2012

Scary KPC outbreak at the NIH

Today's Washington Post contains an article that will send chills down the spine of every hospital epidemiologist and infection preventionist in the world. It describes an outbreak of carbapenem-resistant Klebsiella pneumoniae (KPC) at the hospital of the National Institutes of Health in Bethesda. Over a 6-month period last year, 17 patients became colonized or infected with KPC; of these 8 developed bloodstream infections. A total of 11 patients died; 6 of these deaths were attributed to the infection.

The outbreak was terminated using typical interventions (cohorting of patients and staff, active surveillance cultures, contact precautions, and enhanced cleaning protocols). Further details can be found in a report in Science Translational Medicine (abstract here, full text requires subscription). This report outlines how the outbreak was able to be tracked using whole genome sequencing, which allowed the epidemiologists to determine that the entire outbreak could be traced to a single patient. Traditional molecular typing with PFGE would not have provided enough discriminatory power to do this.

KPC is a horrible organism. As shown here, over half of colonized patients developed bloodstream infection and three-quarters of those died. This bug makes MRSA look like a teddy bear. We desperately need new antibiotics to combat this organism as many strains are resistant to all available antibiotics.

Monday, August 20, 2012

The rest of the (hand hygiene) story

Anyone who works in hospital infection prevention knows that there are a bizillion published articles on hand hygiene--when to do it, how to do it, which product to use, how long to do it, and how to measure it. Much less is written about what to do afterwards (i.e., what's the best way to dry your hands?). This month's Mayo Clinic Proceedings has a systematic review on hand drying. You can find the full text of the paper here.

Spoiler alert:  
Paper towels win hands down.

Friday, August 17, 2012

Another reason to quit smoking: C. difficile Infection

A recent study in PLoS ONE from Mary Rogers and co-authors at the Ann Arbor VA and the University of Michigan looked at C. difficile infection (CDI) rates in a cohort of almost 17 thousand Americans over the age of 50.  They used survey data from the Health and Retirement Study linked to CMS data and identified CDI using ICD-9 codes (which are valid in CDI, unlike MRSA). They found that current smokers had 80% higher rates of CDI and former smokers had 33% higher rates compared to never smokers. Possible reasons given for the association include Clostridium species on the cigarettes themselves, high rates of antibiotics among elderly smokers and altered gut microbiota in smokers. Each of these would be another good reason to quit smoking.


image source: wikipedia/Vinniebar

We Are All Microbe

Most of us probably think we're products of our parents and their parents and their parents' parents. That's certainly true, but their collective contributions are outnumbered 10:1 (100 trillion vs 10 trillion cells) by our microbiome. The Economist cover story from this week highlights the latest thinking around the microbiome and it's implications for science and medicine. They even mention that a "handful of doctors" use fecal transplants to treat C. difficile since transplanting a microbiome is easier than transplanting a kidney. Mike is one of the handful of those doctors. (note: Maryn McKenna's comment on Mike's post from 2 years ago is still one of my favorite) One of the more interesting paragraphs covers the potential use of antibiotics to positively manipulate the microbiome:

"One is more sophisticated deployment of the humble antibiotic, arguably the pharma industry’s most effective invention. At the moment antibiotics are used mainly to kill infections. In the future they might have a more subtle use—to manipulate the mix of bugs within a human, so that good bugs spread at the expense of bad ones."


Part 2: "The human microbiome: Me myself, us" goes into the significance of the microbiome in greater detail.

Thursday, August 16, 2012

An Ounce of Evidence



Ashish Jha, a physician and health policy researcher at Harvard, has a new blog, An Ounce of Evidence. His first posting is an interesting and informative piece on hospital rankings and includes guest posts by staffers at Consumer Reports and Leap Frog. It's clearly worth taking a look.

Is C. diff the new MRSA?

Today's USA Today has an article on the problem of C. difficile in US hospitals. You can read the article here. To be sure, C. diff is a big problem in US hospitals. However, I fear that we could follow the MRSA path to control. That is, instead of addressing the tough issues that control will require--better usage of antibiotics and assiduous attention to hand hygiene--we'll instead be forced into strategies that sell products for big companies. And we may even allow industry to convince lawmakers to create laws that create a market for their products. Only time will tell...

Image:  CDC

Wednesday, August 15, 2012

What happens when an anthropologist studies hand hygiene?

Heather Reisinger is a medical anthropologist at the University of Iowa and the Iowa City VA.  Her research and service efforts have involved hand-hygiene improvement efforts in VA, including leading a system-wide hand-hygiene practice survey and interacting with operations partners to improve hand hygiene.  She recently discussed her efforts to balance research with process improvement in the latest issue of Anthropology News.  Her questions focus on discrepancies between reported hand-hygiene compliance rates (e.g. 90%) and the lower rates observed during research funded compliance monitoring (e.g. 40%) and other important but unanswered questions.  Worth a read.

Reference: Reisinger H et al. "Improving Hand Hygiene: The Intriguing Space Between Health Services Research and Clinical Operations" Anthropology News, August 2012

Image source: Ethnography Museum, Budapest

Tuesday, August 14, 2012

IDWeek and Social Media


Note: This isn't meant to offend - I post this because I genuinely want to see this meeting succeed and worry that we are missing tremendous opportunities to advance our cause(s)

For the past year, I've been suggesting through discussions and emails that SHEA and IDWeek could utilize social media to engage scientists and the public. I've even written about the importance of marketing your science earlier this year. So far, nothing has happened. For example, I just reviewed the number of twitter followers of SHEA (171) and IDWeek (57).  If you look at APIC (1,163 followers) + AJIC (362), ASM (2,816) and IDSA (1,749) they do much better. That is, someone seems to care about social media...

How can a huge meeting with expected attendance of >5,000 have only 57 followers, only follow 5 "people" and have 28 total tweets (close to zero about science)? It's because they don't take it seriously. If I had submitted an abstract and it was selected as a poster or podium presentation, I would want the meeting to advertise my science to a huge group of attendees and science journalists, but IDWeek has been close to useless on that front so far. There have been numerous times that authors, attendees and our blog have mentioned IDWeek in a tweet or blog post and there have been almost zero retweets, zero follows and zero interaction. If the meeting is not engaged in the science and its promotion, why should I submit my science to IDWeek? What do I get out of it?

We have 8 weeks or so to the meeting - there's still some time, but it's running out. Let's step it up IDWeek.

EOR

Monday, August 13, 2012

Should I accept this abstract?

I’ve been reviewing scientific abstracts for IDWeek, which is how I know that there is going to be a lot of excellent work presented there—if you haven’t registered, do so now!

During my review, I ran across the very succinct abstract below (I’m not making this up).

I suspect this one might not make the cut (we require a more detailed data summary). Sadly, it does sum up quite a lot of the hospital infection prevention literature.  On a positive note, what makes much of the work being presented in San Diego worth hearing is the slow but steady progress our discipline is making in study design and analysis.


Friday, August 10, 2012

Understanding Patient Safety

I just finished reading Understanding Patient Safety, 2nd edition. It's a single authored text by Bob Wachter, one of the pioneers of the patient safety movement. I found it to be a top-to-bottom overview of the topic, filled with useful examples, and not only easily readable but also an enjoyable read.

This is a useful book for just about everyone in healthcare, and probably should be required reading for all health sciences students. I think it's of particular value to hospital epidemiologists because many of us may not be aware of developments in other safety issues outside of HAIs.

You can view the table of contents here.


 



Flu Friday (in August!)

The CDC issued some updates today on the influenza A (H3N2) variant virus. There are now 153 confirmed cases of flu A H3N2v, reported from Indiana, Ohio, Illinois and Hawaii. There is no evidence yet that the virus is particularly virulent (only two hospitalizations, and no deaths thus far). The median age of cases (7 years) is likely related to lower levels of cross protective antibodies in kids (kids also may be more likely to cuddle up to pigs at agricultural fairs). In every confirmed case where a contact history was obtained, there was contact with swine or attendance at a fair where swine were present (I’m still awaiting data on what percentage of the Midwestern population has not attended an event where swine were present). The interim case definition requires swine contact in the week prior to illness, or an epi link to a confirmed H3N2v case.

On the testing front, CDC reports a nice evaluation of the commercial rapid diagnostic tests, demonstrating great variability in performance—negative results from these tests don’t exclude the diagnosis. Molecular tests should perform well, but may give “unsubtypable” results or a falsely positive result for human H3 viruses. Any samples from suspected cases should be sent to state public health labs, where initial testing will be performed (followed by testing at CDC if results of the CDC RT-PCR panel demonstrate presence of the nucleoprotein, influenza A and seasonal H3 targets).


Cartoon image of influenza virus from the CDC Public Health Image Library

Thursday, August 9, 2012

HAI Rates are a Red Herring


"Fictional" Hospital CMO: "Why should I care about hand hygiene or environmental cleaning if I have no CLABSI or CAUTI in my hospital?"

Don't take this the wrong way, since I'd never want a patient to develop a CLABSI or VAP, but I think our focus on device infections is actually harming patients in the long run. If we convince ourselves, like that CMO quoted above or QI and patient safety folks, that we can just prevent device infections (never mind define them away) and everything will be fine, we are missing the bigger picture. The bigger picture is antibiotic resistance and I've yet to see any evidence that our antibiograms are improving.

When did hospital epidemiologists forget we were infectious disease physicians?

In September's ICHE Kerri Thom and colleagues in Maryland published a sobering reminder that resistant pathogens are increasing, particularly Gram-negative pathogens. They (COI alert, I'm a co-author) completed an Acinetobacter baumannii prevalence survey of all mechanically ventilated patients in the state of Maryland. They swabbed intubated patients in 40 of 57 hospitals and collected sputum and/or perianal swabs from  92% of all eligible patients in those hospitals.  What they found was staggering.  Fully 34% of patients were colonized or infected with Acinetobacter baumannii with 16% in acute care settings and an astounding 63% in long-term care settings carrying the pathogen. Even more worryingly, many strains were highly drug resistant with 46% of isolates in long-term care described as "extensively drug resistant," meaning there were no effective therapies - polymixin anyone?

Why does this matter?  Resistant pathogens cause untreatable infections and result in terrible situations like patients being removed from organ transplant waiting lists. These pathogens also carry resistance genes and serve as reservoirs for emerging resistance in other pathogens like E. coli. So, while I'm sure these Maryland hospitals all report zero CLABSI or CAUTI, I guarantee that they all have patients infected and dying of Acinetobacter baumannii and other MDR-Gram negative pathogens. Until we make investments in the science behind hand hygiene improvement, environmental cleaning and other methods for transmission prevention and until we invest in antimicrobial discovery, patients will increasingly die of these untreatable infections.

Luckily, when a kidney transplant patient dies of MDR-Acinetobacter sepsis, the hospital CMO can still sleep at night. At least the patient didn't die of a CLABSI.  I'm sure the patient's family will find comfort in that.


red herring image source: misocrazy

Tuesday, August 7, 2012

Hmmmm...should we follow evidence or dogma?

So there's another systematic review of the literature on influenza vaccination of healthcare workers in the August issue of Emerging Infectious Diseases (full text here). Guess what? The results are quite similar to those of the Cochrane Group. The authors of the new study write:
"HCWs would be justified in claiming that the current evidence base is not especially strong and heavily weighted toward the benefits to patients receiving care in long-term care facilities, although limited evidence would not necessarily legitimize nonacceptance."
The authors go on to state that vaccination seems reasonable since there is likely some protection of high-risk patients.

On the basis of this new analysis, I haven't changed my mind. I still think HCWs should get vaccinated against influenza. I even think that we should make it hard for them to not get vaccinated (require signed declination, mandate educational sessions, etc). But I continue to believe that you can't fire HCWs who are not vaccinated based on the current state of evidence. To do so makes a mockery of what epidemiologists are supposed to espouse above all--decisions made on evidence, not dogma.

It's ok to shut down your MRSA PCR machine

There's a recent paper in the American Journal of Infection Control outlining an an active surveillance program for MRSA at a small acute care hospital in Montana. Patients found to be colonized were then placed in contact precautions. Of note, the hospital has had 1-2 MRSA healthcare associated infections yearly for the last several years. In 2010, isolation of asymptomatically colonized patients was discontinued with no subsequent increase in MRSA HAIs noted. The authors conclude that contact precautions are not necessary for asymptomatically colonized patients and the cost of consumable products for contact precautions was an unnecessary expense. I agree with the authors, but would go further to question the value of performing active surveillance for MRSA in a hospital with 1-2 infections per year.

Photo:  CDC

Sunday, August 5, 2012

Animals

Those of you who follow our Facebook page have noted several recent stories on the zoonotic disease front. New human cases were reported of the influenza A (H3N2) variant, a swine virus that thus far appears to cause mild disease and has limited-to-no transmissibility from human-to-human (virtually all cases have been among those with direct pig contact, often at summer fairs). Meanwhile, an avian H3N8 strain was reported to be the cause of a recent fatal outbreak of pneumonia among New England harbor seals—whenever an avian strain demonstrates adaptation to a mammalian host, it is cause for concern. This development further stresses the importance of open and transparent work to understand the key features of virulent influenza strains that predict human infection and transmission (in other words, lift the “voluntary moratorium”). Finally, we have a very provocative report suggesting that rabies virus exposure, at least in remote communities in the Peruvian Amazon, may not always result in infection and death. Rabies is notorious for having a human fatality rate approaching 100%, with very few reports of survival after clinical infection. It is surprising, then, to find evidence for nonlethal rabies virus infection among those with bat exposure and no history of vaccination. Too soon, really, to determine if this finding is explained by unique genetic-immunologic characteristics of this remote population, or if there are other mechanisms of nonlethal exposure that have not yet been identified.

While we are on the topic, I’d like to plug my favorite blog about infections in animals, Worms and Germs, by Drs. Scott Weese and Maureen Anderson of the Ontario Veterinary College's Centre for Public Health and Zoonoses.

Thursday, August 2, 2012

Hey Hey, My My - Nurse burnout associated with HAI?


There is an interesting new paper out in this month's AJIC getting some press.  The authors completed an ecological study using a 2006 survey of nurses working in Pennsylvania hospitals to a 2006 PA hospital report on HAIs and AHA hospital characteristic data. Burnout was defined using a validated survey instrument for exhaustion and anyone over the "norm" (median/mean?) was considered burned out. When they put both nurse-patient staffing ratios and "burnout" into linear regression models they found that burnout was associated with higher rates of both healthcare associated UTIs and surgical site infections.

This is a fun paper, as it's important to keep thinking about ways we can structurally prevent HAIs.  Just a few caveats. I would only report the model that included either nurse staffing or burnout since I suspect they're colinear and shouldn't be included in the same model (ie avoid Model #3).  Another concern is that this is an ecological study; there is no way to show that specific nurses with higher reported "burnout" actually took care of patients with higher infection rates; the truth could actually be the opposite of what was reported.  A better study would link individual nurses to individual patients.  Still, all nurses deserve a good masseuse - can't you see they're burned out!