Like hand hygiene, getting workers to stay home when sick is an example of a horizontal infection prevention strategy. Horizontal strategies are multipotent (not aimed at a single pathogen), generally simple methods. While most humans inherently know that it's not a good idea to come to work with fever or diarrhea, many either can't or won't stay home and risk infecting co-workers, customers, or patients.
One major reason for presenteeism is lack of sick time, a particular problem for food service workers and other low wage earners. But the healthcare industry has its problems too, as many hospitals provide workers with paid time off (PTO) as opposed to sick leave. PTO is time that can be used for vacation, personal days or sick time. While this has some advantages, it also presents problems. For example, time off for illness reduces vacation time, so a sick worker may have to choose between working with the flu or going to Disney World. A worker that has used all of his PTO, may also feel compelled to work while ill.
New York City took a step in the right direction yesterday when it mandated five days of sick leave with pay for employees who work in companies with 20 or more workers. Smaller businesses will be forced to allow workers to have sick leave without pay with no threat of job loss.
From a public health perspective, the first step to reducing presenteeism is ensuring that workers have sick leave. However, for doctors and nurses, we'll need other solutions to keep them home. Perhaps denormalization of presenteeism would be a start. Maybe someday coming to the hospital while sick will be viewed like smoking on rounds. While I bet that sounds implausible to many, I remember attending physicians smoking during morning report when I was a medical student in the mid-1980s.
So kudos to New York, the only city in the world with a mayor who has a school of public health named after him!
What if you suddenly developed a low-grade temperature, stomach pains and felt exhausted at the end of the day? Would you think that someone was poisoning your tea with 60% alcohol hand rub? Me neither. But that's what started happening to a Newport News (Virginia) middle school teacher starting this past fall. She didn't find out that she was being poisoned until this month. Two 13 year-old students have been charged with felonies.
Now what's going to happen? Will hand-rub be banned from schools resulting in more preventable URIs and other viral infections each winter? I hope not but it's eerily similar to something I remember happening back in the early days of the community MRSA epidemic in Baltimore. Marc-Oliver Wright and other's noted that hospitalized prisoners were at high risk for MRSA colonization and infection. When we approached the healthcare officials at the prisons, we were told that they couldn't install hand rub or soap since the former would be lit on fire or ingested and the latter would be used as a blunt weapon.
After the Sandy Hook School tragedy, some have suggested we arm our teachers with automatic weapons. Now we may have to remove alcohol hand rub from schools. Maybe we should just move the schools into the prisons...they already have the weapons protection, cafeterias, libraries and playgrounds. They may soon add the lack of hand hygiene.
Our blog turns four today! As Mike pointed out when the blog was only one year old, our longevity has greatly exceeded the brief lifespan of most new blogs. Readership keeps growing, in fits and starts, and I remain amazed at the number of visitors the site receives each day. We truly thank you, our readers, for your ongoing interest.
Rather than repeating the story of how this blog began, and why I continue to blog, I’ll refer you to my post from the blog’s second birthday. I’ll repeat only one point: this blog has become such a valuable “online catalogue” for me, and the process of blogging has become such a useful way for me to organize my thoughts, that I think I’d continue to blog even if no one else was reading...
I’m not sure we’ve ever gone 10 days without a blog post, but clearly we have been on break here since the middle of March. My travel started with a trip to Atlanta for a HICPAC meeting, and ended at the beach pictured above. Eli spent some family time in Florida as well (perhaps he’s preparing to bring the Disney Experience to the VA system?). Mike is in an undisclosed location, no doubt preparing for this blog’s fourth birthday celebration.
The HICPAC meeting left me with many questions to ponder while walking the beach at Siesta Key:
Should an underpowered or otherwise flawed randomized controlled trial carry more weight than a good quasi-experimental or observational study?
Should certain “foundational” practices (e.g. hand hygiene) be evaluated similarly to other infection prevention interventions, particularly when the evidentiary base for their effectiveness in various settings is meager?
If a “bundle” of practices is recommended with a specific evidence “grade”, should each individual practice within that bundle also be subject to a graded recommendation?
Should HICPAC make graded recommendations only about the practice itself (what to do), or also about the implementation of the practice (how to do it)?
If the evidence base for prevention is sufficiently poor, is it better to have no guideline at all (and to use those resources to fund studies to improve the evidence base)?
Having answered these questions to my own satisfaction, I was able to spend the rest of the week pondering larger questions about meaning and existence. Such as, why were the Iowa Hawkeyes left out of the NCAA men's basketball tournament but Middle Tennessee State made it in?
The Washington Post is reporting today on the death of a renal transplant recipient from rabies. Interestingly, the transplant occurred 15 months prior, yet the donor and recipient rabies viruses were genetically identical. It's another case of organs being transplanted from a donor who died of encephalitis, which still strikes me as absurd. We've blogged before about this topic in cases involving rabies and Balamuthia.
Three years in this blog I wrote: It seems to me that at a minimum there should be an immediate ban on transplanting organs from donors with undiagnosed encephalitides in cases where transplantation is not immediately life-saving (e.g., cornea, kidney, intestine, pancreas, musculoskeletal grafts). And where transplantation is potentially immediately life-saving (e.g., heart, liver), full disclosure of the donor's diagnosis and its implications should be made available as part of the informed consent process.
I feel like I should expand on this recent post about why relying upon prompt laboratory detection of CRE carriers is unlikely to help contain spread (aside from during local outbreak responses). Why shouldn’t screening be a pillar of our prevention efforts, particularly given the inspiring stories of local and regional CRE control that utilized screening to detect carriers? Leaving aside the question of how important screening was among multiple simultaneous interventions, these tworeports are from academic tertiary care centers with robust on-site laboratory support and external funding to provide financial support for state-of-the-art screening approaches (such as rapid PCR detection of KPC producers).
The sad fact is that this level of clinical microbiology laboratory support is far from the norm. The trend over the past two decades has been toward consolidation and outsourcing of laboratory services, and reducing local resources available for diagnostic microbiology labs. I spoke about this trend, and some of the consequences, at the 5th Decennial conference a few years ago (you can view the slide set here). In the decade that has passed since we noted frequent errors in testing and reporting of blood culture results in a sample of 14 hospital laboratories, I doubt that much has improved. Yes, there are CAP proficiency surveys, but for several reasons these are not good indicators of actual laboratory performance. And while outsourcing microbiology to a regional lab may make short-term financial and technical sense for some hospitals, it also removes lab support further from the front line of patient care and infection prevention, prolongs turnaround times, and comes with a host of pre- and post-analytic problems.
If current fiscal and political trends continue, with additional cuts to public health infrastructure and CDC’s budget, it is difficult to imagine that we can do much in the short term to shore up our surveillance capabilities to respond to the CRE threat.
Last week was officially “CRE” (carbapenem-resistant Enterobacteriaceae) week, and I encourage anyone who hasn’t done so to read Eli’s excellentposts about the entirely predictable emergence and spread of these bad bugs. Before this crisis disappears down the media memory hole, it is worth mentioning one additional line of defense against CRE that is not up to the challenge: our clinical microbiology laboratories. This is particularly concerning when the new recommendations made by the CDC in response to CRE require additional laboratory support: (1) confirmatory testing and determination of the carbapenem resistance mechanism for CRE, and (2) rectal screening cultures of all patients admitted to U.S. hospitals who were hospitalized outside the U.S. in the prior 6 months.
The CDC provides a phenotypic method for CRE screening, and there are several other published methods (including commercial screening agars), but these approaches don’t provide clinically relevant turnaround times, nor do they tell us which mechanism is at work (e.g. KPC, NDM, VIM, IMP, etc.). Some referral centers use home-brew PCR tests for the most common carbapenemase in the U.S. (KPC), and there are commercial assays being developed that utilize real-time multiplex PCR to detect several enzymes at once, but these tests aren’t available to most labs. So if your hospital lab does find a bug that looks like a possible CRE (after 24-72 hours!), it can perform the Hodge Test (which isn’t great for emerging carbapenemases), send the bug out to a reference lab….and wait for the result.
I completely understand why the CDC has recommended new screening questions + rectal swabbing as part of CRE response. However, trying to keep these organisms from entering our hospitals and long-term care facilities using screening questions and rectal swabs is like depending upon a poorly built levee to hold back floodwaters.
Dramatic advances in hand hygiene, environmental disinfection, and antimicrobial stewardship, on the other hand, would be the prevention equivalent of moving out of the floodplain to higher ground. Allow me to dream, please!
Over the past few years there has been a huge push across the country to reduce healthcare associated infections (HAIs). This has created a big market for entrepreneurs. In fact, according to BCC Research the market for HAI prevention products is expected to be $14 billion by 2016, at which time the market for antibiotics to treat HAIs is expected to be only $6 billion. Some hospitals have purchased high-tech hand hygiene monitoring devices that use radiofrequency identification, some have installed video cameras to observe hand hygiene, while others have invested in hydrogen peroxide robots. At my hospital we're investing in coat hooks. As we prepare to roll back contact precautions (i.e., no longer requiring patients with VRE or MRSA to be isolated except in special circumstances), we thought it would be good to re-visit bare below the elbows to reduce clothing contamination and promote good hand hygiene.
Several years ago, our infection control committee endorsed the bare-below-the-elbows concept. This means short sleeves, no neck ties, and no white coats. We specifically crafted our policy as a recommendation not a mandate since we believed there was enough evidence to recommend this intervention but not enough to require it. It was an intentional soft sell. Since the recommendation was made we have seen more physicians in scrubs, and our nurses are nearly all in scrubs. We still have the issue of long sleeves under scrubs when the weather is chilly, and we still have many doctors who just can't ditch the white coat.
So our latest effort, the "Hang it up" campaign, is a little more pragmatic, giving healthcare workers more options to comply with bare below the elbows. We're placing coat hooks in all physician team rooms and nurse work rooms with a poster (the physician poster is shown below) asking healthcare workers to hang up their jacket or white coat before going to see a patient. If a male doctor feels compelled to wear a necktie, we advise him to tuck it in his shirt.
We would have preferred to have coat hooks placed between patient rooms on wards, but fire regulations wouldn't allow that.
As I have said before, the longer I work in infection prevention, the more I believe it's a behavioral science. Old habits die hard, so the next few months should be quite interesting to observe.
"You may ask yourself, well, how did I get here?" - the Talking Heads
It's been a busy week in antibiotic resistance. From Tuesday's MMWR early release identifying terrifyingly large increases in CRE until today, there has been non-stop media coverage. This morning, I had a long discussion with a colleague about CRE and it got me thinking about how we got to this point. As Maryn McKenna so astutely said this week: "it will be interesting to see whether the news sinks in this time." So, how did we get here?
1981: What we now call AIDS was recognized as a clinical syndrome. Thus began the cascade of infectious diseases research towards a full-scale and massively-funded response to the AIDS crisis. This has been an incredibly successful, if not yet complete effort. At the 2011 IDSA meeting, Cornell's Trip Gulick said that we now have 10,000 possible combinations of antiviral therapy agents for HIV. Thirty years after the virus was discovered in 1983, the progress has just been incredible. Sure, we've not yet achieved a significant number of cures and an effective vaccine remains just out of reach, but if you'd asked most of us in 1990 if we'd wanted to switch places with 2013, we would have said yes in a heartbeat.
2013: Most ID research efforts still target HIV and other viral pathogens. As we published last year, 2009 NIAID funding for HIV was $1.3 billion, while funding for all ESCKAPE pathogens was around $49 million. When we reported this disparity, it seemed quite obvious that we needed to fund more research of antibacterial resistant pathogens. However, nothing is ever that easy. One of the peer-reviewers of our paper made the excellent point that the "historically poor funding for antimicrobial resistance over the years along with the exit of pharma from the field has led to a lack of significant infrastructure. There may not be enough productive labs to send more money to at this point." So, even if the US wanted to fund more research, it may take time to train or retrain investigators to undertake the relevant research.
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Now that I've shared some brief thoughts on why we are where we are, I have some further thoughts on where we should go. First, as I said earlier this week, we need a national response to CRE and antimicrobial resistance in general. This response needs to be horizontal in approach, as Mike Edmond and Dick Wenzel recommended several years ago. For it is quite clear that if we follow the vertical approach recommended by the CDC and others, swab for CRE and isolate, that this will bankrupt hospitals and ultimately fail.
This surveillance approach will bankrupt us, because CRE isn't the only "nightmare" in our hospitals. Back in 2010, when Dan was discussing MRSA on NPR, he said so eloquently: "MRSA is not the only bad bug out there. It's just the most famous." And along with MRSA, we have VRE and ESBL and C. difficile and Acinetobacter and MDR-Pseudomonas. You see, we might not be able to take this single-hospital outbreak approach and extrapolate it to the entire country and 10+ pathogens. And if there is one lesson we should be taking away from the NIH CRE outbreak it's not that new-fangled whole genome sequencing stopped the outbreak (because it didn't), it's that the outbreak spread and killed many patients despite herculean efforts to detect and eliminate it. Furthermore, if we target MRSA like many hospitals are now doing with chlorhexidine (CHG) baths, this approach could select for Gram-negative bacteria like CRE.
My recommendations:
(1) Invest significantly in antimicrobial discovery. Apart from the need for new treatment options, optimal control of resistant pathogens may depend on availability of effective antibiotics.
(2) Invest in studies to improve compliance with hand hygiene – only 4 studies on this topic since 1980 per a recent Cochrane Review. Compliance is terrible, but currently the approach is to blame healthcare workers and not figure out how to help them easily clean their hands.
(3) Study universal gowning and gloving (several studies are ongoing). Dentists wear gloves with every patient, why not doctors?
(4) Undertake studies to further optimize environmental source control
(5) Actually study antimicrobial stewardship. Stop yelling at patients and clinicians to not use antimicrobials. Actually fund studies that use advertising and other other messaging techniques that have a chance to be effective.
Oh, and no more ridiculous hand hygiene song and dance videos...unless they include folks like the Talking Heads...
There is an early release MMWR out today describing the recent trends in carbapenem-resistant Enterobacteriaceae (CRE) using data from the CDC's National Healthcare Safety Network (NHSN) and the Surveillance Network–USA (TSN). CRE infections, such as UTIs or intra-abdominal infections, cannot be treated with currently available antibiotics. The results of the MMWR study are not surprising - there are more CRE now - yet I find them rather chilling.
The proportion of Enterobacteriaceae that were CRE rose from 1.2% in 2001 to 4.2% in 2011 in NHSN hospitals and to 1.4% by 2010 in TSN facilities. In Klebsiella species, the situation is dire with 10.4% classified as CRE in 2011. By 2012, 4.6% of all facilities, 3.9% of short stay hospitals and 17.8% of long-term acute-care hospitals reported at least one CRE in their facility.
So things are pretty bad, at least 17.8% bad.
What can we do about this? This is what they say in the abstract: "Interventions exist that could slow the dissemination of CRE. Health departments are well positioned to play a leading role in prevention efforts by assisting with surveillance, situational awareness, and coordinating prevention efforts."
Which interventions? Certainly there are no evidence-based interventions, unless we call an uncontrolled quasi-experimental study evidence. The CDC authors made reference to VRE control efforts in the Siouxland, MRSA control efforts in The Netherlands and CRE control efforts in Israel. I think these are poor and overly optimistic comparisons for several reasons. For one, the first two efforts targeted Gram-positive bacteria and it's unclear if we can extrapolate these to control efforts targeting MDR-GNRs. For example, we have effective antibiotics for VRE and MRSA (quinupristin/dalfopristin-approved in 1999; linezolid-approved in 2000, daptomycin-approved in 2003) but not for CRE. Additionally, we can decolonize for MRSA but not CRE.
However, the most important aspect of the Netherlands and Israel examples were that they instituted NATIONAL RESPONSES aimed at MRSA and CRE. There are no such national efforts here in the US targeting CRE. This is what we have in the US per the MMWR report: "six states have made CRE reportable, and three additional states are actively pursuing this option." This is not a national response. This is a national tragedy. We can't expect CDC to say they can't handle the problem and we can't expect states to say they can't handle the problem. They are working their butts off with minimal support and no national will for a coordinated response. If we don't have a national response soon - it will be too late, but I'm not holding my breath.
I will leave you with an excerpt outlining the Israeli national CRE response from Mitch Schwaber's excellent report in CID. Do you think we have anything close to this going on here in the US? Me neither.
Update: Looks like NPR's "All Things Considered" will post an audio discussion of the CRE issue around 7pm ET here.
The first case-control study I performed early in my hospital epidemiology fellowship at the University of Iowa was an examination of risk factors for VRE (vancomycin-resistant enterococcal) bloodstream infection in an outbreak among oncology and bone marrow transplant patients at a community hospital. Little was known about VRE at the time. One very strong risk factor emerged from my data: receiving an antibiotic that had significant activity against anaerobes. This 20-year old observation has since been replicated and subsequently proven in experimental animal models. In mice treated with anti-anaerobic drugs, VRE burden can rise to the point that these organisms constitute 99% of the bacteria in the gut. Although VRE are relatively nonvirulent organisms, in neutropenic hosts they can cause bloodstream infection following gut colonization and translocation across the intestinal mucosa.
Now comes a very interesting study from Memorial Sloan Kettering Cancer Center in this month's Infection and Immunity. The investigators induced VRE colonization in mice, then performed fecal transplantation using stool from untreated, noncolonized mice. Within 15 days VRE could not be recovered from the feces of the treated mice. They next determined that the presence of the obligate anaerobe Barnesiella in donor stool was most closely associated with the therapeutic effect. They then evaluated stool cultures of patients who had undergone allogeneic stem cell transplants and found that those patients harboring Barnesiella in their GI tracts were protected from having VRE domination of their fecal flora.
The authors put their findings into an interesting evolutionary perspective in the paper's discussion:
"Oxygen-intolerant bacteria have limited options on the earth’s surface, and the metazoan colon represents an essential, and for many anaerobic species, sole, sanctuary. Despite their density in the colon and their proximity to the bloodstream, obligate anaerobes rarely cause human disease and their survival depends on their host’s survival. Obligate anaerobes of the gut promote their host’s survival by limiting the expansion of oxygen-tolerant bacteria, which, by and large, are the subset containing most of the intestinal pathogens. Our results suggest that Barnesiella spp., by restricting the growth of VRE, regulate the composition of the microbiota and optimize host survival."
I always teach the medical students that after they read a paper they should ask themselves to identify the implications of the paper for their practice. In this case, I suspect the implication is that my future is filled with performing many, many more fecal transplants. Although the yuk factor is very high, reimbursement is bad, and the time input is significant, the powerful results and grateful patients make doing it truly worthwhile.
Photo: Dr. Ella Barnes, British intestinal bacteriologist and namesake of the VRE conquistador.
