Monday, December 31, 2012

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

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

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

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

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


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

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

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

Wednesday, December 26, 2012

The lunacy continues

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

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

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

Photo:  3M

Saturday, December 22, 2012

Happy Holidays from CHIP

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

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

Thursday, December 20, 2012

Should we go over (to) the Cliff?

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

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

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

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

Wednesday, December 19, 2012

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

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

Here's a summary graphic from the article:

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

Trouble at the Pittsburgh VA

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

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

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

Tuesday, December 18, 2012

Moving away from contact precautions

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

Photo: Stericycle

Monday, December 17, 2012

Contact precautions: who wins, who loses?

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

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

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

Photo from Cardinal Health

Saturday, December 15, 2012

Stuff we can't talk about

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

I have no special expertise, so I’ll spare you my opinions. However, I do think that gun violence should be studied and prevented in the same way that we study and prevent other forms of harm. That starts with understanding some of the epidemiology. I’ll outsource this to Ezra Klein, who reviews some basic facts in this excellent post.
"If roads were collapsing all across the United States, killing dozens of drivers, we would surely see that as a moment to talk about what we could do to keep roads from collapsing. If terrorists were detonating bombs in port after port, you can be sure Congress would be working to upgrade the nation’s security measures. If a plague was ripping through communities, public-health officials would be working feverishly to contain it."

My thoughts exactly...


Friday, December 14, 2012

Thanks Teresa!

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

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

Sunday, December 9, 2012

Beware of dishes!

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

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

Saturday, December 8, 2012

An outbreak linked to a cardiac surgeon

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

The article notes:
The infections raise questions about what health conditions should prevent a surgeon from operating and how to get the best protection from surgical gloves. Surgeons with open sores or known infections aren't supposed to operate, but there is no national standard on what to do if they have skin inflammation, said Rekha Murthy, medical director of the hospital's epidemiology department. She added that there were also no national standards on types of gloves used, whether to wear double gloves or how many times surgeons should change those gloves during a procedure.
Rekha's comments point out a few examples of the many unknowns in healthcare epidemiology. As hospital epidemiologists we are held accountable to fix problems, but often we're bereft of the answers to such basic questions. This has been a recurrent theme on this blog, and as Eli has stressed, we lack funding to perform the research to fill the gaps in our knowledge base. After this week's Infectious Diseases fellowship match, which demonstrated that few young doctors remain interested in our field, it appears that we may also eventually lack the human resources to address these problems.

Friday, December 7, 2012

Don't be one, get one...

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

Thursday, December 6, 2012

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

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

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

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

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

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

Wednesday, December 5, 2012

Infection Control Image of the Day

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

Sunday, December 2, 2012

The ghosts of the "prior room occupant"

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

-From the movie The Shining, 1980 

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

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