Wednesday, October 31, 2012

Hikers and hand hygiene

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

Monday, October 29, 2012

Fungal meningitis outbreak still unfolding

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

Here are some recent articles on the outbreak:

Thursday, October 25, 2012

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

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


h/t Melissa Ward

Presenteeism - Don't Come to Work Sick!

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

Tuesday, October 23, 2012

Thanks Jenn!

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

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

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

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

Monday, October 22, 2012

The boiling frog and antibacterial resistance

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

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

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




Friday, October 19, 2012

IDWeek!

It has been a great IDWeek so far, with almost 7000 registered attendees.  I've moderated and attended several excellent sessions that we'll be blogging on next week, when we have a few minutes to absorb it all!  Susan Huang's presentation of the REDUCE MRSA trial results occurred today, so we'll no doubt be discussing how these data further support Mike's long contention that horizontal infection prevention strategies are superior for MRSA control. Yesterday we received an excellent update on the fungal meningitis outbreak from Tom Chiller, Carol Kauffman and Tom Patterson.  Carol and Tom also just coauthored (with Pete Pappas) this summary from today's NEJM, check it out!   

Monday, October 15, 2012

Happy Global Handwashing Day!!

Hey everybody!  Break out the soap and water and clap those soapy hands together as we celebrate the 5th anniversary of Global Handwashing Day! October 15, 2012

 

And if you're heading to IDWeek in San Diego, come to session #5, a symposia titled: "Hand Hygiene, State-of-the-art: Surveillance and Compliance" where I will be moderating and the good Dr. Edmond will be speaking about creative ways to improve hand hygiene. Other speakers include Dinah Gould, Phil Polgreen and Kate Ellingson.  Should be a great sesssion.

Sunday, October 14, 2012

Fungal Meningitis Update

It has been a few days since Mike last blogged on this curious but devastating outbreak, and time to mention a few developments. First off, it is now clear that the outbreak isn’t primarily due to Aspergillus, but rather to a little-known soil (or dematiaceious) fungus called Exserohilum rostratum. The Mycology Online site at the University of Adelaide is an excellent quick guide to the gory details of identification (be sure to look carefully for the ellipsoidal to fusiform poroconidia that are formed apically on a sympodially elongating geniculate conidiophore!).

Exserohilum are common environmental molds, and rarely cause human disease. Slow-growing and challenging to identify in the lab, it would be difficult to imagine an agent that would be more insidious and refractory to diagnosis and treatment once injected into an immune-privileged site. This is why the number of cases continues to increase long after the compounding pharmacy responsible for distribution has been shut down (and also why treatment may not be effective by the time a case is recognized).

The CDC website is the best source of authoritative information (as of today, 198 cases and 15 deaths), and this excellent article illustrates the degree to which our CDC and public health colleagues are working to get a handle on this outbreak (a special shout-out to Shawn Lockhart, featured in the photo—Shawn did his clinical microbiology training with us here at Iowa). Those who were exposed to the affected lots of injectable steroids are literally being tracked down one-by-one, using any resources available to state public health authorities (while I was at HICPAC, one public health official described local police knocking on doors to inform those at risk).

Finally, I wanted to highlight the fact that your IDWeek planners have been working overtime to put together a late-breaker session at IDWeek to update all attendees on this outbreak. We will have representation from CDC, a clinical mycologist, and a clinician involved in the care of affected patients. So if you are heading to San Diego please attend!

Thursday, October 11, 2012

Does pay for performance in HAI pay off?

The data is piling up suggesting that the CMS policy for nonpayment for HAIs have had little impact on reducing preventable HAIs in acute-care settings. The straw that might break the camel's back is a study in this week's NEJM by Grace Lee and colleagues.  Using a quasi-experimental design and time-series analysis, this AHRQ-funded study looked to see if there was a change in HAI rates after (vs before) the October 2008 nonpayment policy went into effect. 398 NHSN hospital provided data. The results are pretty conclusive: there were no changes in CLABSI, CAUTI or VAP after the implementation of the policy.  In the figures below you can see that things are getting better, just not due to nonpayment.

Of course this is not surprising. Peter McNair published a very nice study in Health Affairs (2009) that estimated that the total financial impact across the entire US would be about $1.1 million annually for six avoidable conditions. When you divide that amount by the number of US hospitals you get...about nothing per hospital. I think CMS might need a bigger stick.

Source: Lee GM et al. NEJM 2012; 367: 1428-37


Wednesday, October 10, 2012

Infection Prevention During Space Travel


One of the highlights of any conference is chatting with other investigators and hearing about all the creative projects they've been working on.  A perfect example occurred last week in Potsdam when Len Mermel described his multi-year effort to understand infection risks that might arise during prolonged human space travel. Why is this important? Even a short roundtrip to our neighbor Mars might take 400-450 days given that the Mars Curiosity Rover took 254 days to reach the planet's surface. After he described his findings, I was increasingly excited to read the review, and fortunately, I didn't have to wait long, since the pre-print just appeared in CID.

First of all, this is a very well written paper and was a lot of fun to read. He highlights evidence that suggests that microgravity might enhance expression of virulence factors and increase biofilm formation. On the human side, there is evidence that the immune system becomes increasingly dysregulated, which could increase the risk of infections from pathogens such as herpesviruses, and that anaerobic flora in the gut is decreased, which could increase the risk of aerobic pathogens such as Pseudomonas. There is also evidence of enhanced S. aureus skin colonization and Enterobacteriaceae in the upper airways. If that isn't scary enough, microbes have been shown to "survive in free-floating condensate" kinda like what happens in Cleveland or Detroit.

The rest of the paper describes the infection prevention challenges facing the astronauts, what microbial changes to expect and specific issues related to the confines of the spacecraft or habitat. He then thinks ahead by suggesting potential countermeasures that could be implemented using existing vaccines, decolonization therapies and spacecraft modifications designed to minimize risks of transmission. Finally, he lists several important unanswered questions to guide future research.

Excellent work Len!


Chlorhexidine: Also prevents general malaise and existential crises


We can now add Clostridium difficile to the long list of maladies that can be prevented by the zealous application of chlorhexidine (in this study, a 4% aqueous solution, first thrice-weekly and then daily, hospital-wide). Yes, I realize that this study (from our good friends in Nebraska) was quasi-experimental (lacking a concurrent control group), and I realize that it was funded by a manufacturer of chlorhexidine (a company whose name I cannot spell or pronounce).

Potential confounders include changes in diagnostic testing during the course of the study (but these changes should have made a decrease more difficult to detect, because they moved to increasingly sensitive assays), and the introduction of other C. difficile control measures (pre-emptive isolation and bleach disinfection were introduced a couple years before the start of this study, but could have had some delayed impact). Finally, there is the biological plausibility issue—if chlorhexidine isn’t sporicidal, how could it impact C. difficile rates? The authors suggest it could be due to physical removal of spores, and/or to killing of vegetative bacteria or prevention of spore germination. All seem plausible, but require further study.

Monday, October 8, 2012

Chicago Cubs are #1: With the most disgusting ballpark!!!

I've been away for a week, hanging out in Potsdam with some infection control folk and am only now catching up on the terrible outbreaks and important developments that occurred in my absence. One report that must be personally disturbing for our esteemed colleague, microbiologist and favorite Cub's fan Dan is the recent survey of Major League Baseball Stadium cleanliness that found historic Wrigley Field to be the grossest, dirtiest, most vile baseball park ever!  All 30 ballparks were graded on 79 review criteria. Some highlights for the Cubs: 21% hand hygiene compliance in the men's bathrooms - more urinals than sinks apparently and vendors handling food and money with the same hands, Yum!  Hmm, come to think of it, maybe this explains the poor attendance at Wrigley this year?

See the full rankings here.

h/t Mark Vander Weg

The Wonderful ESCMID-SHEA Course - Potsdam


I just returned from Potsdam and the 14th ESCMID-SHEA Training Course in Hospital Epidemiology. The faculty and students were all incredible people and I really enjoyed the interactive discussions.  It all started with a wonderful dinner at Professor Petra Gastmeier's home and thanks to the Aesculap Akademie staff, we truly were Sans Souci "Without Worries." Looking forward to future courses in Brussels and other wonderful locales.

Friday, October 5, 2012

35 cases now and counting...

For those of you following the Aspergillus nosocomial meningitis outbreak, there are new newspaper articles with additional details here and here. The New York Times article today focused on the lack of oversight of compounding pharmacies. Also, CDC has a webpage with useful information for clinicians that can be found here.
Map:  CDC.

Thursday, October 4, 2012

Aspergillus outbreak expands

The outbreak of nosocomial meningitis due to Aspergillus that we noted yesterday is larger than initially reported. Today's New York Times now reports that there have been 34 cases (4 deaths) that involve patients in 5 states. The cases have been traced to contaminated methylprednisolone solution used for epidural injections that was compounded at a pharmacy in Massachusetts.

CDC is recommending that suspected cases be treated with IV voriconazole and consideration be given to the addition of IV amphotericin B.

Photo:  Janet Carr, CDC.

Wednesday, October 3, 2012

Nosocomial Aspergillus meningitis outbreak

This morning's New York Times reports on an alarming outbreak of Aspergillus meningitis in Tennessee. At this point there have been 14 cases, two of whom have died. All patients received steroid injections into their lumbar spines. From time to time we see sporadic cases of infections due to injections of steroids, most commonly into joints, but the vast majority of those cases are due to Staph. aureus. In the current outbreak, it is postulated that the contamination occurred in a compounding pharmacy prior to shipment to the facility where the injections were performed. Because Aspergillus is an extremely rare cause of meningitis, it is unlikely that clinicians would suspect this infection and it's also unlikely that the organism would be seen on initial microscopic view of the spinal fluid. Thus, delays in diagnosis would not be surprising.

Photo:  CDC.

Tuesday, October 2, 2012

HAI stories

Via the CDC's Safe Healthcare blog, a healthcare-associated infection story worth reading, told from the perspective of Brenda Helms, Infection Preventionist. 

Monday, October 1, 2012

Who will win the all-important Lyme conspiracy theorist vote?

I have no idea, but the Romney-Ryan campaign seems to have the advantage. Slate and the Weekly Standard describe the details of a direct mail campaign in Virginia, courting the votes of those who believe that there exists a conspiracy to underdiagnose and undertreat Lyme Disease. Here’s an excerpt from the mailer:
SUPPORT TREATMENT
Encourage increased options for treatment of Lyme Disease and provide local physicians with protection from lawsuits to ensure they can treat the disease with the aggressive antibiotics that are required.
Translation: we’re in favor of protecting doctors who commit malpractice and place patients’ lives at risk by prescribing weeks of unnecessary antibiotic therapy for a disease that their patients do not have.

During my first few years of infectious diseases practice, I was asked to consult on a young mother admitted to the ICU for severe sepsis due to drug-resistant Pseudomonas, acquired by virtue of the weeks of intravenous ceftriaxone she’d been prescribed for a misdiagnosis of “chronic Lyme”. Her actual diagnosis was post-partum depression, for which she was eventually treated successfully, after barely surviving her hospitalization. Others haven’t been so lucky.