Please, please don't try this at home!

Today, I ran across a letter in the American Journal of Infection Control that left me nearly apoplectic. In the letter, the authors argue that nonhospitalized patients with C. difficile infection should be on contact precautions while AT HOME! Let's think this through this, people. Are we going to confine an elderly person to their bedroom, and wear gowns and gloves when we walk into that room? If grandma eats dinner with the family are they all going to sit at the table wrapped in plastic? What about Fluffy the cat? Gowns and gloves for her, too?

There's actually an excellent population-based study that evaluated the risk of infection in household contacts. Over 2,000 C. difficile index cases were evaluated, and the risk of infection in household contacts was 0.4%. Let's use some common sense: if the infected person can have their own bathroom that would be great, clean the bathroom with bleach, and practice good hand hygiene. But for God's sake, let's not make it a leprosarium.

Prevention, anyone?

Thanks to Eli’s recommendation, I watched the Frontline documentary on antimicrobial resistance last night. The culprits (MRSA, pan-resistant Stenotrophomonas, NDM- and KPC-producers) are fearsome, and the stories are riveting. The most haunting line is exactly ten minutes in, when Will Lyman (the somber voice of Frontline) intones that “Addy and her mother had entered the post-antibiotic era”. The statement is both shocking and true, and one we’ve covered before. Overall, this is perhaps the best lay media treatment of this issue that I’ve seen, and features many of our eloquent friends and colleagues. In particular, pay attention to Dr. John Quinn, an expert in gram negative resistance who died earlier this month after a battle with cancer. He will be sorely missed. You can watch the documentary in full here. 

One minor criticism: too much emphasis on drug development and new technology (e.g. whole genome sequencing, “robot” cleaning), not enough discussion of the hard work of basic infection prevention (hand hygiene, contact precautions, environmental cleaning). I know from discussion with those involved that these topics were discussed during interviews, but probably not deemed compelling enough to survive the editing process. New drugs buy some time and can be life-saving, but only until bacteria catch up…..and genome sequencing didn’t halt the NIH outbreak, strict enforcement of basic prevention measures did. I hear a lot of general nihilism about hand hygiene (adherence rates will never exceed 60%, high rates can never be sustained, etc., etc.). The truth is that we have much more work to do to better understand and solve the hand hygiene problem. 

Frontline plans a second show in the spring of 2014 that covers the role of antimicrobial use in driving resistance, which I look forward to seeing. Might I suggest they begin planning a third installment, dedicated exclusively to the problem of hand hygiene in healthcare settings?

Photo of Ignaz Semmelweis from Wikipedia Commons

NIGHTMARE BACTERIA coming to your PBS station October 22nd!

It's not quite the Zombie Apocalypse, but these carbepenem-resistant nightmare bacteria are clearly the next scariest thing. PBS's Frontline seems to think so. Producer/Writer/Director Rick Young has pulled together a 1-hour investigation into antibacterial resistant infections including (it appears) NDM-1 and the NIH CRE outbreak. From the promotional material it also seems that the program will touch on the lack of investment in drug discovery in addition to excess use, as causes of the epidemic. Remember, check your local listings.

CAUTI SCHMAUTI ! (part 2)

I recently blogged about about the big project to reduce UTIs that, well, wasn't all that effective. It reduced CAUTIs by 0.41 infections/1,000 catheter days. This seemed to me to be a high-burden, low-impact intervention. But wait, there's more....

The November issue of Infection Control and Hospital Epidemiology has a retrospective cohort study by investigators at Baylor University. Over a 9-month period they examined all cases of positive urine cultures occurring in the presence of a urinary catheter in 5 medical wards and 5 extended care wards. This yielded 308 patients with catheter-associated bacteriuria. They went on to subclassify cases as CAUTIs and performed a 30-day follow-up. They found 2 cases of secondary bloodstream infection in the 128 CAUTI cases identified (1.6%). They cite a prior study by Dennis Maki that found 1 secondary BSI in 235 cases of CAUTI (0.4%). Now it's important to remember that the primary reason we are interested in CAUTI is the risk of secondary BSI because that's where we have the serious morbidity and mortality.

So let's to try to put this into perspective. We'll look at the worst case scenario first (i.e., we'll use the pre-intervention CUSP rate of infection [2.55 CAUTI/1,000 catheter days] and we'll use the Baylor risk of secondary BSI [1.6%]. If I apply these assumptions to my 850-bed hospital with 49,000 catheter days per year, I can expect 2 BSIs due to CAUTI yearly. Repeating this exercise with the CUSP post-intervention CAUTI rate [2.14/1,000 catheter days] and Maki's rate of secondary BSI [0.4%], I can expect 1 BSI due to CAUTI every 2 years. Now the 2012 rate of CAUTI at my hospital was actually 2.15 (essentially the same as the post-intervention rate in the CUSP report), so I can expect 1 BSI secondary to CAUTI every 7 months to 2 years. When I think about the resources and energy that we are expending to reduce our CAUTI rate, I have to conclude that there's not much bang for the buck. Put more eloquently, the opportunity cost is high. Or perhaps more to the point: chasing CAUTI is a fool's errand.

Photo: Saltanat Ebli, Wikimedia

Welcome back CDC (and USDA, FDA, NLM etc) folks!

There are so many unsung and underpaid federal employees that work tirelessly to keep our water clean, food safe and track and prevent infectious diseases. They were all really missed when they were away. It was particularly sad to not hear the CDC talks and latest data at IDWeek; what a waste.

But they are all back (at least until early 2014) and I hope they don't have to go away anytime soon. Sometimes you don't appreciate something until it is taken away. We appreciate you! Thanks and thanks for your service.

Oh, can you get on updating the influenza map? Come on, you've had a couple hours!  ;)

Addendum: I'm thinking a humorous story or cartoon would be of the guy responsible for reading the 16 million unread emails at CDC that have piled up. I think it should be one guy and I'd like to recommend a particular person for the job. But I'm not saying who that might be.

IDWeek 2013: Media, Social Media, and Open Access

One of the great things about sitting on the planning committee of a national meeting is the ability to put together sessions that are a bit "outside the box" if you will.  During the planning of IDWeek 2013, I had the opportunity to attend the ScienceOnline2013 Conference in Raleigh where I reconnected with Maryn McKenna and met Jonathan Eisen. I thought that many of the concepts that the science journalists (McKenna) and scientists (Eisen and Smith) discussed at ScienceOnline were directly applicable and perhaps urgently needed by the public health community that attends IDWeek. Specifically, I felt that public health was a little too heavy on the "health" and a little too light on the "public." So I worked with my colleagues on the planning committee, including Scott Fridkin and Dan Diekema, to craft a session that focused on three major methods for selling public health science to the public.

The first important topic was open-access publication. If the public and journalists don't have access to your science because it's buried behind a paywall, then it doesn't even exist.  The second topic was social media, which is a method by which scientists and public health practitioners can communicate their science or policies directly to the public including science journalists. Finally, we needed a speaker to help explain how best to interact with journalists to communicate our science and messages. So, we were very lucky to have Jonathan Eisen, Tara Smith and Maryn McKenna speak at our session at IDWeek earlier this month in San Francisco.

There are several sources available for those of you interested in the session's content:

Jonathan Eisen wrote a nice post describing the entire session and also created a Storify (a collection of live tweets associated with the session) covering all three talks, both of which you can read here at one of his blogs. He's also posted his slides on slideshare.

Tara Smith posted her slides on social media at Figshare. She also posted the slides from her excellent S. aureus in animals talk, which you can access through her blog.

A good time to ditch contact precautions?

I get that no one likes to don gowns and gloves before seeing patients, particularly ID consultants who see a large number of patients colonized/infected with MDROs. I understand that touching is important for healing and that somehow wearing gloves impedes the healing touch. I even see why some still think that contact precautions place patients at greater risk for medical errors, even if the data supporting that contention is lacking. What I don't get is why infection prevention folks are pillorying one of the most effective methods we have in MDRO transmission prevention right when we need it the most.

My thoughts:
1) MDRO rates, particularly for Gram-negative pathogens like CRE and Acinetobacter are increasing
2) We have no antibiotics in our quiver, so prevention is our only hope for a decade+
3) Most prior room occupant studies are flawed and when proper methods are used, prior room occupants are not a risk factor - thus the environment isn't the only answer.
4) Hand hygiene compliance is only 60% - I know some are claiming 90%+ on their reports, but it's simply not true.
5) Gloves are massively effective in reducing the burden of organisms on hands and CP have now been shown to be effective in an RCT - (if you can look past the JAMA trial nihilists)

Which brings me to the table below modified from a study we completed a few years ago. You'll notice the red circle highlighting the per room entry contamination rate of healthcare workers hands with A. baumannii when hand hygiene compliance is 60%. The green circle highlights the contamination rate when gloves are worn with the 90% compliance achieved in the BUGG study (even ignoring that universal CP is associated with higher HH compliance).  You can see that when a healthcare worker enters an A. baumannii+ patient's room, 15% of the time they will leave the room with A. baumannii on their hands. If the hospital practices universal CP, it will be 3% of the time.

So, I get why people hate contact precautions, particularly ID-trained hospital epidemiologists. I just don't get the delight with which they limit their use given that CP are supported by the strongest evidence that our dismal science can muster. I suspect, again, that I won't have to live that long to witness their regret.

Contact precautions are so last year

I was going to post some thoughts on the BUGG Study (and I did put a quick summary into an F1000 recommendation). However, I have little to add to the authors’ own discussion, Preeti Malani’s editorial, and Mike’s previous posts. In short: a great study that advances the field, and given the mixed results (primary versus secondary outcomes) it will be hypothesis-generating but not practice-changing. I do, though, have a couple related observations… 

First, we should stop conflating MRSA and VRE, whether for study designs or for prevention strategies. They differ too much—in preferred ecological niche, inherent and acquired resistance mechanisms, virulence, epidemiology, and almost certainly also in relative effectiveness of prevention strategies. The authors include some discussion of this point in the paper. 

Second, the hypothesis being tested in the BUGG study is definitely swimming upstream, against what I perceive as slow movement away from contact precautions. Mike has posted about their new approach at VCU, but other centers have also moved away from the CDC MDRO guidance regarding use of contact precautions. I’m on an informal e-mail group of academic hospital epidemiologists, and last week one of them asked whether centers were still using contact precautions for E. coli-ESBL producers. The responses provided further evidence for a move away from isolating for E.coli-ESBLs, MRSA and VRE in some large academic centers. I suspect this represents the tip of the iceberg, particularly as hospitals seek to improve their patient satisfaction scores.

Of course, there’s a big difference between an ICU-specific universal glove-gown intervention and hospital-wide, microbiology-driven contact precautions use, and it is easy to hypothesize why the former would work better than the latter.

CAUTI, SCHMAUTI !

I just took a look at the report on the National Stop CAUTI Project (free full text here). This project uses the Comprehensive Unit-based Safety Program (CUSP) at 850 hospitals, and the report summarizes data from the first year of the project. The results were rather modest--from a baseline CAUTI rate of 2.55/1,000 catheter days there was a decrease to 2.14/1,000 catheter days. This represents a 16% relative reduction and translates to the avoidance of a whopping 0.41 infections per 1,000 catheter days. To provide some perspective, my 850-bed hospital has 49,000 catheter-days per year. An intervention of that magnitude would lead to a reduction of 20 infections yearly. Now 20 is better than nothing, but I would have to classify this as a high-burden, low-benefit intervention. And all of this begs the question: would it make more sense to take all the effort expended on CAUTI and re-direct it elsewhere (maybe hand hygiene)? Just sayin'....

Photo:  LAMMICO

Guest Post: IDWeek in Review

This is a special guest post by Dan Morgan, MD MS. He's an assistant professor at the University of Maryland, Baltimore.

After a hectic few days of conferencing at IDWeek I’m looking forward to my more hermit-like routine. Although fields of knowledge tend to advance relatively slowly, this IDWeek was inspiring for a number of interesting ideas emerging in hospital epidemiology. Although I'm sure I missed most of what happened while I was talking in the hallways or waiting in the lunch line, I'm still mulling over a few ideas on flights back to the East Coast that I would like to share.

Antimicrobial-resistance is increasing. This is a worldwide phenomenon in which what happens in one country affects other countries. This is an issue in the hospital with carbapenem-resistant enterobacteriaceae and Acinetobacter and although declining, MRSA is still a large problem. The community also is critical, holding a huge burden of resistance not only in MRSA but gonorrhea and other sexually transmitted infections, along with other pathogens like malaria and TB.

Manipulation of the microbiome is beginning to be seen as a therapeutic target. The remarkable experience with fecal transplants was frequently mentioned and a neater, cleaner method for taking a pill containing poop to populate the colonic microbiome is under evaluation in an ongoing trial in Canada from Thomas Louie at colleagues. Beyond C. difficile, nasal MRSA decolonization through microbiome manipulation was discussed by Mary-Claire Roghmann and the exploratory papers on obesity and other non-infectious diseases was reviewed by Bob Weinstein.

Public policies to promote HAI prevention were hailed as a success in a video presentation from Denise Cardo, and regardless of ones perspective, as stated by David Calfee and Brad Spellberg, public reporting of process measures and outcomes is here to stay.

Infection prevention outside the hospital was highlighted in multiple sessions. From debates on contact precautions in nursing homes, interventional studies by Lona Moody showing a benefit secondary to improved attention to standard infection control in long-term care facilities, and Mary Hayden's presentation on a bundle to prevent CRE in LTACHs.

Methodology of infection prevention studies is improving. Multiple cluster trials were discussed (those above by Mary and Lona and the BUGG study by Anthony Harris—full disclosure, I was a co-author with Anthony on this study) and methods to perform more rigorous quasi-experimental and pragmatic studies were well described by Jessina McGregor, Ebb Lautenbach and Marin Schweitzer in an advanced epidemiological session.

Technology is improving but several technologies (e.g interventions for room cleaning (Curtis Donskey) or hand hygiene (Kal Gupta)). However, when they are ready for prime time they will need to be integrated appropriately as one part of healthcare epidemiology.

Chlorhexidine patient bathing is the new black. After recent NEJM papers by Susan Huang, Mike Climo (and most other luminaries in healthcare epidemiology) there seems to be a move towards widespread adoption in the United States. At IDWeek, CHG was also presented as potentially beneficial for CRE prevention in LTACHs and despite nervousness around FDA warnings, is being used in NICUs. Some expressed concern for the possibility for future decreasing susceptibility to CHG.

Shutdowns have an effect! A power outage on Saturday ended some sessions early but the more remarkable shutdown was federal. Notable were the absences of organizer Scott Fridkin and many leaders who work for the CDC or VA. The rapture realized!

Don't BUGG me! (some more)

A few days ago I blogged about the BUGG study. This paper has generated a fair amount of media coverage, and as I looked through the headlines this morning, I was struck by the variability of the messages they seem to contain. Take a look at the headlines below all describing the BUGG study:

• Gloves, Gowns in ICUs Cut Down on MRSA
• Cheaper Way to Stop MRSA Adds No Patient Risk
• Widespread Glove, Gown Use In ICUs Could Reduce Spread Of MRSA
• Gloves and gowns use in ICU not completely effective against infection, says study
• ICU gloves and gowns may reduce infection
• Use of gloves, gowns by health care workers for ICU patient contact does not reduce MRSA infection
• Gloves, Gowns In ICU Reduces MRSA 40 Percent
• Gloves and Gowns Don't Cut Hospital Care Infections, A Study Finds
• Universal gloves, gowns in ICU reduced MRSA acquisition
• Universal glove use not associated with reduction in acquiring antibiotic-resistant bacteria
• Widespread gown and glove use by health-care workers in ICU reduces MRSA 40 percent
• Gown And Glove Use In ICU Cuts MRSA by 40 Pct
• Gloves and Gowns Don't Stop Spread of All Infections in Hospitals
• ICU Gloves and Gowns Might Reduce MRSA Infection, Study Says
• Universal Gown And Glove Use By Health-Care Workers In ICU Reduces MRSA 40 Percent
• Gloves and gowns do not protect against MRSA or VRE, study shows
• Study Examines Effect of Use of Gloves and Gowns For All Patient Contact in ICUs on MRSA or VRE
• Universal gown and glove use by health-care workers in ICU reduces MRSA 40 percent
• Wearing gown and gloves for all ICU patient contact reduces MRSA infections by 40%
• Study-Hospital Precautions Do Nothing to Stop Infections

Interestingly, if you examine each headline carefully you find that almost every one of them is technically correct, though if you had never read the paper you would likely be very confused. It's a great example of how technical papers get translated for the general public. In this case it's related to understanding the difference between colonization and infection, the differences between types of outcomes (are we talking about device-associated infections or pathogen-specific infections?), and combined vs single outcomes (MRSA and VRE combined vs. MRSA and VRE evaluated separately). Lastly, even if you read the paper and have a good understanding of its findings, the implications of the study will be different based on the value judgments of the reader. Despite all of the confusion, I think that you'll seldom find a better designed or better executed study in healthcare epidemiology. In Facebook parlance, "it's complicated."

Photo: Las Vegas Guardian Express

I hope I live long enough

Mike has had his say regarding universal gloves and gowns. I'm a huge fan of Mike's push for horizontal interventions like hand hygiene, but I was surprised when I read that he is pushing universal chlorhexidine bathing in his hospital. I will keep this post short so you can quickly move down to read his post, but I have a couple comments. First - chlorhexidine is an "antibiotic" and resistance already exists.  Second, if there is one thing we know about overuse (i.e. universal use) of antibiotics is that it leads to resistance. Third, I know that CHG is fashionable (like antibiotic cycling once was) and you can't fight fashion. Finally, if we really want clean hands, when you add the BUGG study's gloving+hand-hygiene compliance this would equal ~95% hand cleanliness.

In the meantime, I will sit on the sidelines and wait for CHG resistance to rise and the many MDR-acinetobacter and other GNR outbreaks that will occur secondary to it's overuse. Despite the title of my post, I suspect I won't have to wait too long.

Addendum: looking through the twitter chatter after the BUGG study was released, I noticed a disturbing trend of HCW complaining more about the burden of wearing contact precautions than the burden of HAI.

Don't BUGG me!

JAMA has just published the BUGG (Benefits of Universal Glove and Gown) study online (free full text here). This important, well-designed study was led by Anthony Harris (nice video of Anthony discussing the study here). It's a 9-month, multicenter, cluster randomized study in 20 medical and surgical ICUs that compares universal contact precautions (i.e., gowns and gloves for all patient care) to "standard" contact precautions (i.e., gowns and gloves for the care of patients with epidemiologically important organisms). The primary outcome evaluated was acquisition of MRSA or VRE. Patients were cultured for both organisms on admission and discharge from the ICU.

In a nutshell, the findings were as follows:

• There was no significant difference in the rate of acquisition of MRSA and VRE combined.
• When MRSA and VRE were evaluated separately, there was no difference in the acquisition of VRE, but there was a significant reduction in MRSA acquisition in the universal contact precautions group with an incremental benefit of 3 fewer MRSA acquisitions per 1,000 patient days.
• There was no difference in device-related infections (CLABSI, CAUTI, or VAP) between the two groups and no difference in mortality.
• There was no difference in adverse events between the two groups when evaluated by the IHI Global trigger tool (for what that's worth...).
• Hand hygiene rates were higher in the universal gowns/gloves study arm.
• As might be expected, there were fewer patient visits by healthcare workers in the universal gown/glove study arm.

So, how do we put this study into perspective? Should the study entice hospitals to begin universal gloving and gowning in the ICU setting? 

Let's assume you have a 15-bed ICU that admits 1,250 patients yearly with an average length of stay of 4 days (i.e., 5,000 patient-days annually). Assuming 10.5% of patients require contact precautions (this proportion comes from the control arm in the BUGG study), 131 patients would require isolation. Alternatively, under universal contact precautions, all 1,250 patients would be isolated. So by isolating an additional 1,119 patients we would prevent an additional 15 patients from acquiring MRSA (i.e., 3 per 1,000 patient days). Assuming 20% of the colonized patients go on to develop infection, 3 additional MRSA infections would be prevented with universal contact precautions. Bottom line: to prevent 3 additional infections we needed to isolate an additional 1,100 patients. Given that I'm a utilitarian and that I believe that the burden of contact precautions on patients is high, my assessment is that the benefit of universal gloves and gowns is outweighed by the overall burden on patients. Now it's true that MDR-GNRs and C. difficile weren't evaluated in the study so we may not be evaluating the full benefit of the intervention. But for now, don't BUGG me--I'm still pushing universal chlorhexidine bathing, high rates of hand hygiene compliance, and no isolation of patients with MRSA or VRE.

Addendum (10/6/13):  More on this study in Time.

Photo: Duke Infection Control Outreach Network (DICON)

Seek and ye shall find? Not so much...

Our understanding of the epidemiology of C. difficile infections continues to evolve. Dan recently blogged on a new paper that shows that a high proportion of healthcare associated cases are not due to transmission in the hospital. Another new paper in BMC Infectious Diseases (full text here) takes a look at an important question: are colonized healthcare workers involved in the transmission of Clostridium difficile in the hospital setting? At a large hospital in Australia a convenience sample of 128 healthcare workers (mostly nurses) had stool samples tested for C. difficile. Over 40% had known contact with C. difficile infected patients. Specimens were tested by ELISA and culture. No carriers were found. Given how difficult it is to get stool samples from HCWs, the authors should be commended.

Two other similar studies have been performed in the last 5 years. One found no colonized HCWs out of 112 tested, and the other found 4 of 30 (13% positive). So based on limited data it appears that colonization of healthcare workers probably does not play a major role in the transmission dynamics of C. difficile, though larger studies are needed.

Photo: Maddie Meyer/The Washington Post

Here come the maskers

Recently, the New York State Health Department mandated that all healthcare workers either be vaccinated against influenza or wear a mask. This week’s JAMA has a commentary by the ethicist Art Caplan and New York’s Commissioner of Health, Dr. Nirav Shah. In the JAMA piece they argue the ethical imperative underlying the mask ruling. You can read about the ruling here and the JAMA commentary here (free full text). Unvaccinated HCWs will be required to wear the mask during periods of widespread influenza activity. It’s important to note that over the past 6 years, the period of widespread activity in New York varied from 11 to 22 weeks. That’s a long time to wear a mask, which is required in any area where patients are typically present. The document notes that this includes the cafeteria, though the unvaccinated worker is allowed to be mask-free when eating.

For many reasons, I dislike mandatory influenza vaccination. But I despise the mask regulation. I have to question the rationale. It seems to me to be less about ethics and more about being coercive and punitive. It’s wasteful. There have been periods of time when masks were in short supply with the shortage being made worse by the maskers. Most importantly, wearing a mask for prolonged periods of time is impractical—it’s uncomfortable and distracting. If we are going to argue for masking on an ethical basis, since influenza vaccination is only 60% effective at best, wouldn’t it be consistent to argue that all healthcare workers, vaccinated and unvaccinated, should wear a mask? It's also laughable that the ethicist doesn't mention that it's unethical to come to work while sick with influenza, which studies tell us is quite common. Presenteeism remains the elephant in the middle of the room, and reducing it is likely far more important than mandating influenza vaccine or masks to prevent transmission of infectious diseases in the healthcare setting.

Photo: REUTERS/Yuri Maltsev