Newest horizontal intervention: iPad stand + toilet roll holder

From hand hygiene to reducing presenteeism there are many horizontal interventions that are effective in preventing infections in hospital settings. However, there are risks in your own home that are calling out for community-based horizontal interventions. For example, have you ever read a magazine, newspaper or iPad while sitting on the toilet? Me neither. Now, you no longer have to worry about transmitting fecal-oral pathogens via literary fomites thanks to a newly available product: the CTA Digital Pedestal Stand for iPad 2/3/4 with Roll Holder.

This 4-star rated product is currently available for $40 and scrolling through the customer reviews you can see why. Below, I've pasted some comments from reviewer ohjodi for your enjoyment.

Brilliant! Replaces my clumsy tv tray, which didn't match my bathroom decor. I can now Skype (hands-free!) instead of trying to juggle a cell phone. Eliminates the need for a stack of magazines (unsanitary!)... I do wish it had a cup holder, and maybe a basket or tray of sorts to hold a bag of popcorn, chicken nuggets, french fries, bowl of soup, etc. I watch a lot of streaming tv and movies, and I had to knock off one star because after 30 minutes or so my legs start to fall asleep and I have to stand and shake my legs for a few minutes to get the circulation going... My toddler son LOVES THIS for potty-training with Angry Birds!

Multidisciplinary, multifaceted approach to C. difficile prevention - It works!

Clostridium difficile - bad.

Many good people doing a lot of good things to prevent C. difficile - Priceless

That's the basic summary of a recent report in The Joint Commission Journal on Quality and Patient Safety by Len Mermel and colleagues at Rhode Island Hospital. Faced with a high burden of CDI, they implemented a series of six "interventions" targeting C. difficile between 2006 and 2012.  These interventions were: (1) develop a C. difficile hospital infection control plan based on a risk assessment; (2) monitor hospitalwide morbidity and mortality associated with C. difficile infection; (3) improve sensitivity of C. difficile toxin detection in stool specimens using a PCR assay; (4) enhance environmental cleaning of patient rooms and equipment; (5) develop a C. difficile infection treatment plan; and (6) conduct other interventions including attempting antimicrobial stewardship.

Overall, the results were impressive with a 70% reduction in incidence. From a peak of 12.2 cases per 1000 discharges in 2006 rates fell to 3.6/1,000 discharges in 2012 with comparable declines in CDI-related mortality. Using time-series analysis they reported a change in slope of quarterly healthcare-associated CDI cases per 1000 discharges after each intervention, which you can see in the figure below. The slopes of each line are associated with (from left to right) the (1) pre-intervention period, (2) education, outcome reporting and room cleaning monitoring, (3) bleach product use for room cleaning, (4) PCR testing (5) additional room cleaning personal hired with defined responsibilities, (6) equipment cleaning training and monitoring.

Here is the link to the full text of the article (subscription required). Is it me or should Joint Commission's journal be open access in 2013?

Why are we so terrible...

...at hand hygiene? Atul Gawande has a piece in the New Yorker entitled "Slow Ideas", that asks why some innovations (and yes, the act of cleaning hands was once an innovation) are so slow to catch on. He starts the piece by comparing two mid-1800s innovations, anesthesia and surgical antisepsis, and outlining reasons why the former spread so much more readily than the latter.

"So what were the key differences? First, one combatted a visible and immediate problem (pain); the other combatted an invisible problem (germs) whose effects wouldn’t be manifest until well after the operation. Second, although both made life better for patients, only one made life better for doctors. Anesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considered procedure. Listerism, by contrast, required the operator to work in a shower of carbolic acid. Even low dilutions burned the surgeons’ hands. You can imagine why Lister’s crusade might have been a tough sell."

These simple observations are highly relevant to hand hygiene, an innovation that still hasn't completely taken hold after 150 years. Mike was recently in Iowa City to give an excellent talk on hand hygiene and made similar points. Microorganisms are invisible to the naked eye, the diseases they cause have incubation periods that separate cause (poor or absent hand hygiene) from effect (infection, sepsis, death), and an individual failure of performance is almost never linked directly to the adverse outcome. I should let Mike take it from here, but the alternatives to what we've been doing (constantly-evolving campaigns that have impacts which extinguish over time) involve long-term, multi-faceted approaches that have the goal of eventually "hard-wiring" the behavior.

The history of CRE

There's a nice piece in Nature (free full text here) by Maryn McKenna on the history of the emergence of CRE. There's also an accompanying editorial. Worth reading...

Graphic:  Nature.

Huge increase in hand hygiene compliance to...32%!?!?

There is a lot of pressure on hospitals to improve hand hygiene compliance and it seems even more more pressure from industry to install expensive electronic hand hygiene monitoring systems. This investment might be worth it if (A) the systems accurately measure hand hygiene compliance and (B) are cost effective. One additional benefit claimed regarding these electronic hand hygiene surveillance systems (but not yet proven in the peer-reviewed literature) is that these "surveillance" systems actually improve compliance over the long haul.

Last year at IDWeek, John Boyce and colleagues presented results of a quasi-experimental study analyzed using high-quality statistical methods that showed that installation of an electronic "RTLS-based" monitoring system was associated with a 36% decline in entry compliance rate (p=0.191) and 32% decline in the exit compliance (p < 0.001). These declines in directly observed hand hygiene compliance may have been driven by the fact that the badge accuracy was only 60%. Note: it would be nice to see this study published in the peer-reviewed literature. 

Now there is new report out of the 2013 APIC conference assessing a similar system installed at the John Peter Smith Hospital in Fort Worth, Texas. The authors reported a "huge" increase in compliance from 16.5% to 31.7% over a 3-month study period. After the study period the compliance declined to 25.8%.  Some comments: (1) When your hand hygiene compliance rate is 16.5%, you could do almost anything to improve it. I would imagine having your hospital epidemiologist dress up as a clown while carrying around a bottle of hand rub would do it and doing nothing would probably do it too. That's called regression to the mean; (2) I know a 92% relative increase seems large, but when the high point is 32% compliance, I don't think headline writers and companies should get too excited and claim a "Huge increase." Humility and a call for action should probably take precedence over excitement; (3) A 19% relative decline in compliance from 31.7% to 25.8% after 3 months should give them pause, even if it's above baseline.

To sum up the current evidence, electronic hand hygiene monitoring systems may be more accurate than directly observed compliance, although the jury is still out. However, there is no evidence that these systems effectively or cost-effectively sustain hand hygiene compliance improvements. In fact, based on these two abstracts, the evidence appears just the opposite. There needs to be a lot more research and work put into these systems.

Image source: Uzbekistan Global Hand Washing Day (2012)

SwipeSense

The Wall Street Journal is currently running a competition for start up company of the year. From over 500 submissions, 24 were chosen for further consideration. One of them is SwipeSense, a company that has created a product to promote hand hygiene compliance in hospitals. Watch an interview with the young creators here. While you're there, give them your vote! These guys apply human-centered design to hand hygiene.

CDI? Think PPI

Following up on last years MMWR that reported that "nearly 75% of all Clostridium difficile infections (CDI) related to U.S. health care have their onset outside of hospitals", CDC researchers have released a new study in JAMA Internal Medicine looking specifically at the epidemiology of community-associated CDI. The study used data from the Emerging Infections Program, which began to actively collect CDI data in 10 states starting in 2009. This report uses data from 984 patients collected over 29 months with true community-onset CDI, as they excluded community-onset, healthcare facility associated infections.

Somewhat surprisingly, 36% of patients had not received antibiotics and 18% had no outpatient health care exposure. Not surprisingly, 31% of those who had not been exposed to antibiotics had been exposed to PPIs.  I highlighted the risk of CDI from PPIs in my ICPIC talk last month when I discussed this meta-analysis by Kwok and colleagues. In this CDC study, those patients lacking significant outpatient healthcare exposure were also more likely to be exposed to infants and household members with active outpatient healthcare exposure suggesting a potential route of transmission. I agree with the authors primary conclusion that a reduction of outpatient PPI use may be necessary to reduce the risk of CDI. As Mike' pointed out four years ago, PPIs are also associated with HAP, VAP, and SBP, so there are many reasons to be concerned about PPIs.

There is an excellent accompanying editorial by some guy named Kent Sepkowitz, who discusses the "PPI-zation" of the US and the difficulties facing any public health initiative targeting PPIs. For one, PPIs are the third most utilized drug in the US and they are addictive since discontinuation is associated with withdrawal symptoms.  For another, unlike antibiotics, PPIs are widely available over the counter and supported by huge advertising campaigns. Looks like PPIs are here to stay...

Transplantation Associated Rabies

This week's JAMA has a paper and editorial on the recent case of transplantation associated rabies. I blogged about this a few months ago based on the report in the Washington Post. The editorial helps to put all of this in perspective by pointing out that transmission of disease from donor to recipients is a rare occurrence (0.1%) and that many patients die each year while awaiting transplantation. Both the paper and the article make recommendations on how to make the process safer, particularly with regards to how to handle donors with unexplained encephalitis. Even still, as the editorial points out, some donors with infectious encephalitis have had masking conditions (e.g., subarachnoid hemorrhage, intoxication with drugs of abuse, or head trauma). Neither paper mentions that there could be two sets of exclusion criteria for donors--those for when the organ is immediately life saving (primarily heart and liver), and those in which it is not (primarily kidney). Most patients and families would likely be willing to accept a higher level of risk when the transplant is immediately life saving. Fortunately in this case, the three other organ recipients from the rabies infected donor remain infection free. 

Influenza Vaccine Has Miracle Powers After All*

This blog hasn't always been kind to the humble influenza vaccine. So in fairness to our trusty old vaccine friend, I'd like to highlight a recent study published in Lancet ID by Jeffrey Kwong and colleagues in Toronto. They utilized 19 years of data (1993-2011) from the universal health care system databases in Ontario Canada to assess the risk of Guillane-Barré Syndrome (GBS) after influenza vaccination and after influenza infection. They accomplished this using a self-controlled, risk-interval design. This design compares the risk of GBS in a predefined risk interval after exposure to the vaccine or infection and compares it to the risk in the control period outside the selected exposure period. In this case, the exposure period was the first 6 weeks post exposure and the control period was weeks 9-42. Importantly, the patients were conditioned on having GBS in either the risk or control period and each patient served as their own control, which eliminates selection bias. Outcome of GBS was determined using ICD-9 or ICD-10 primary billing codes, which have reported positive predictive values in the 60% range. This is a limitation of the study.

They identified 2831 patients with GBS.  Within the 42 week period, 330 cases were preceded by influenza vaccination and 109 cases were preceded by influenza infection.  The risk of GBS was 1.5 times higher in the initial 6 weeks post vaccination compared to weeks 9-42. The risk peaked in the third week post vaccination with twice the risk. The risk was higher in patients ages 18-64 compared to older adults. Importantly, even this increased risk adds up to one GBS admission per 1 million vaccinated. I also don't think we can rule of influenza infection causing this post vaccine risk since people are more likely to receive vaccine when influenza virus is circulating in the community.

In the 6 weeks post influenza-coded healthcare encounter, the risk of GBS was 15 times higher than baseline and peaked at 61 times higher in the first week post infection. Pending a formal competing risk analysis, patients should continue to be informed of a small increased absolute risk of GBS associated with the vaccine, but also a large risk associated with the infection. Of course, there other benefits associated with influenza vaccination, which should also be discussed with patients. To be clear, influenza vaccine IS a miracle when it's compared to influenza infection.

Image source: wikipedia

*Title is just playing off the title of one of our prior posts on influenza vaccine. Nothing in medicine has miracle powers, since medicine is a science. However, if there is anything close to a miracle it would be vaccines. Antibiotics would be a close second.

Norovirus outbreak with a twist

There's an interesting outbreak investigation in the latest issue of Clinical Infectious Diseases. Twelve employees at an auto dealership developed gastroenteritis after consuming a catered lunch during a business meeting. The dealership wisely contacted the sandwich shop and the health department. At first glance, this appeared to be a typical point-source foodborne outbreak. However, shoe-leather epidemiology uncovered some interesting details. On the day of the outbreak a customer was observed in the women's bathroom with her toddler. An employee noted that the mother was holding the child over a trash can, with stool "spraying" from the child. The baby's diarrhea resulted in extensive environmental contamination of a baby changing station, walls and floor. The employee assisted in the clean-up. Ultimately, it was shown that specimens from the employees and the toddler were positive for identical viral strains of norovirus, and the same viral genotype was found on the baby changing station. So here we have another paper that demonstrates the importance of environmental contamination in the transmission of norovirus. Importantly, some routine cleaning products are not effective against norovirus, for which chlorine bleach remains the recommended cleaning agent.

Swabs are evil (and other sage advice from your friendly clinical microbiologist)

The current state of infectious disease diagnostics is an Achilles’ heel to effective treatment and prevention. Despite the strides we’ve made in many areas (molecular diagnostics for viral respiratory pathogens, for example), for many serious infections our turnaround times are too long to be clinically relevant, test performance characteristics are all over the map, and sample acquisition at the bedside, clinic or OR is inconsistent (“whoa, not sure what this is….let’s stick a swab in it and send it to micro…just check all the boxes on that requisition”). One of the most important jobs of a clinical microbiologist is to communicate early and often with clinicians, to advise them on what samples to obtain, and what tests to order, to maximize the likelihood that the correct diagnosis will be made. 

That’s why I’m so happy that a bevy of clinical microbiologists decided to put as much good advice as they could into one helpful guidance document, found here: A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM).

Whether you’re an intern trying to decide what test to order on a patient you suspect of having filariasis, or a neurosurgeon wondering what to do when that focal brain lesion turns out to be filled with pus, this is your handy reference.

Image of E. coli growth from CDC Public Health Image Library

57 Days of Diarrhea: Iowa and Nebraska Cyclospora Outbreak

As if living out here in the heartland wasn't exciting enough, news is quickly spreading (although not as quickly as the disease and ensuing panic) of a cyclospora outbreak in Iowa and Nebraska. Recent reports suggest that there have been at least 18 cases in Nebraska and perhaps 25 in Iowa. The Iowa Department of Public Health reports that as of Monday there were 22 cases and that the outbreak seems to have begun in mid-June. No source has been identified. What's a bit interesting is the focus in the IDPH brief and subsequent media reports on a 57-days duration (if untreated).  Many folks I've talked to are focusing solely on 57 days, as the news reports make it sound like if you get cyclospora, you might as well camp out in your bathroom for a couple months.  Perhaps the IDPH and media reports could mention that trimethoprim/sulfamethoxazole (bactrim) is a readily available and effective therapy? This might reduce the panic.

Dan made a radio appearance a few days ago to discuss the outbreak - you can read the transcript here. Interestingly, the segment mentioned that prior to this outbreak there were only 10 reported cases of cyclospora over past 20 years in Iowa.

A handwashing nudge

As a hospital epidemiologist, I'm always looking for ways to nudge people to wash their hands. Nudges guide a person to do the right thing (i.e., encourage compliance) without a mandate. Here's the latest one, which was featured by NPR yesterday: the sink-urinal. This allows men to pee in the bottom part of the fixture and wash their hands in the top. It provides a constant reminder to wash your hands. It's environmentally friendly as it uses gray water (from the sink) to flush the urinal. Plus, it comes in an assortment of colors; what more could you ask for?

Photos: Ingus Bajars/Courtesy of Kaspar Jursons

The donor perspective

Today's New York Times has an interesting essay on fecal transplantation with an interesting twist: it's written by a stool donor. The recipient has inflammatory bowel disease. While there is not much evidence regarding fecal transplant for inflammatory bowel disease at this point, there is growing interest. When one compares the safety profile of fecal transplant versus those of highly immunosuppressive therapies for IBD, it's easy to see why many patients might be willing to pursue fecal transplant. I recently spoke to an internist at an academic medical center, who told me that several of his gastroenterology colleagues are informally recommending to patients that fecal transplant may be worth pursuing for IBD. Oh, the power of poo...

Graphic: Katie Scott, New York Times