Global Conspiracy to Hinder US MRSA Control Efforts Uncovered. US and Swiss Scientists Implicated

I was going to title this post "Making Shit Up" but then thought better of it. First of all, profanity can be offensive to some and for reasons that will hopefully become clear, there was a lot of crap written but some of it wasn't made up. It was just that it was twisted and some really great scientists and their science were denigrated. In addition, many scientists were mentioned in an unprofessional manner (first names?) and perhaps some points bordered on ad hominem. Thus, rather than limiting myself to name calling, which lies below ad hominem on Paul Graham's Hierarchy of Disagreement, I've decided to aim a little bit let me begin my counterargument.

First, please step away from this post and go read the 2-page commentary just published in AAC titled: "A Perspective on How the United States Fell behind Northern Europe in the Battle against Methicillin-Resistant Staphylococcus aureus."

Some thoughts. First, the authors suggest in their title that the US is falling behind Northern Europe in MRSA control. Little evidence is provided to support this claim other than that the proportion of S. aureus infections caused by MRSA is higher in the US. No mention is made of livestock-associated MRSA or MSSA or even MRSA related mortality. In addition, the authors focus on only one aspect as a possible cause for this difference between the US and Northern Europe - the US doesn't have legislatively mandated universal active detection and isolation (ADI).

The authors explain that everything would have been wonderful in the US if the 2003 SHEA guidelines recommending ADI were just followed. No mention was made of the fact that Northern Europe lies at the latitude of Anchorage Alaska and that environment might play a role. No mention was made of other potential differences that could influence the carriage rates of this human commensal. And when you read it closely, you realize the commentary authors aren't just upset that the US lacks mandatory ADI but conjure evidence that there's actually an anti-ADI conspiracy aimed at preventing legislative mandates. One supported by antisurveillance activists named Huang and Huskins, and mysterious JAMA Swiss folks, and Diekema and Climo and meddling yet unnamed kids like Weber and Edmond writing position statements and editorials closing cases.

According to Kavanagh et al. it all started with the 2006 HICPAC statement that suggested to consider ADI while requesting more evidence and the SHEA-APIC position paper in 2007 by Weber (and Huang and Huskins) that came out against legislative mandates for ADI. You see, according to Kavanagh and his colleagues, Huang and Huskins would later spend years writing grants and completing complicated and intentionally imperfect studies at a huge personal cost in a twisted antisurveillance plot! Even against these odds, the US Congress held a hearing to push through mandatory ADI but just then unnamed JAMA Swiss folks published a study finding universal ADI ineffective and Diekema and Climo agreed as much in their editorial. Even if we overlook the obvious conspiracy given the timing of the publications, how can these JAMA authors live with themselves suggesting high quality studies overwhelm prior uncontrolled quasi-experimental studies? - the nerve!

But it gets worse (or better)! The authors then highlight the VA MRSA study but suggest that the only reason it was published was that MRSA activists demanded it. And to further prove the conspiracy, they point out that this fantastic study was published in the very same issue of the NEJM as the Huskins STAR-ICU study finding no benefit of ADI. Yup - fact. They then mention limitations (however valid) of the STAR-ICU study while neglecting any potential limitations of the VA study. Very smooth.

The conspiracy theorists authors lose me a bit when they say the US demands surveillance for CRE and HIV and hepatitis C without evidence, and wonder why there's such a high bar for MRSA. It's just not fair!

Further evidence of a conspiracy is offered when they point out that two reviewers of an AHRQ systematic review were none other than the aforementioned Huskins and Diekema! And then it really gets strange. The authors point out that the AHRQ review gave more weight to the higher quality studies that were negative compared to poorly controlled studies that found a benefit. As I read this paragraph I almost become sad, as they basically lost the debate right there. They even mentioned hepatitis C screening again and plead that MRSA ADI evidence is maybe even probably hopefully better. Finally, the REDUCE-MRSA trial by Huang and the accompany editorial by Edmond were mentioned and criticized, you know, because.

They conclude with saying that this whole anti-ADI conspiracy has occurred with the sole purpose of avoiding legislative mandates. They correctly point out that the best way to avoid such mandates is to base clinical decisions on the best available evidence. Fortunately for our patients, that is exactly what we are doing now. We are using the best available evidence as produced by Huskins, Huang, Climo, Diekema, Edmond, Swiss folks like Harbarth and many other colleagues from our ever-growing, evidence-based field of infection control. You know, ADI may be indicated in some settings but not all settings and the way to determine where and when is through more high-quality studies. And there is no conspiracy.


  1. Ok. Nice tirade. A little long... But what do you think of the line of reasoning that it makes sense to copy people who have done a variety of things and achieved excellent results even if you aren't sure which of their many interventions are crucial? Like the Netherlands. This slide set is a lot like one that a visiting Dutchman presented at a big VA prevention conference in San Jose circa 2007. And Amsterdam is about as far North as Vancouver, and wouldn't the climate and temperature be more important than the Northern-ness, anyway.

    1. Are you saying what the VA is doing (ADI) is not enough and we should decolonize like the Netherlands and screen and furlough MRSA positive HCW? What would you do? There are many differences between Northern Europe and the US besides latitude? Plus, Vancouver is not really in or like the US, correct?

      The point of my post was to defend scientists and their science. I actually don't think it was strong enough or long enough.

    2. 10 second google search.

    3. "Compared with other countries, Canada has a lower prevalence of cases than the U.S."

    4. Having people not accidentally infected or injured in hospitals is an applied science. Sometimes it's good just to copy what works then try to figure out why it works and what can be dropped because its not important to the success. If it weren't for people that are not hospital epidemiologists or ID docs the CLABSI rates would probably be where they were 10 years ago, and also mrsa. People like Pronovost and Jain almost made ID docs' heads explode with irritation and fury, but their programs worked. When the VA mrsa program was started a bunch of prominent ID docs got together and wrote a letter to the Secretary saying it was misguided and not a good idea. I remember talking with a couple of them about it at the time at lunch one day at a conference. I didn't know who was right. (Now I realize no one knew.) But waiting for strong physics-type proof for a justification of copying things that work for others is part of why progress has been so slow on most HAIs. Look at the reluctance to adopt the fecal transplant for C diff. How many colectomies and deaths? I don't claim to have the answers, but it's not clear to me that ID docs and HEs do either. But there's certainly no conspiracy - all these things are widely talked about in open forums. When thinking about changing things there too often, to me at least, seems to be a lack of recognition that the status quo is bad. If the status quo was good then changing it could wait for physics-type proof... This is a nice write-up on physics envy...

    5. Are you saying that the weather is why Canada and Northern Europe have lower HAI (mrsa) rates? Really? Is it the heat or the humidity? This is hardly an authoritative source, but here's what it says...

      The study also looked at regional variations across country — hospitals in all 10 provinces and the Northwest Territories took part — and found one notable difference: VRE rates were significantly lower in Eastern Canada than elsewhere in the country.

      The prevalence of MRSA and C. diff cases did not vary much by province or region, although C. difficile rates were lowest in Eastern hospitals.

      “We have to determine what can we learn from that because I don’t have an answer right now as to why there is that difference,” Simor said of the VRE rates in particular. “But the difference exists and it’s real.”

      Compared with other countries, Canada has a lower prevalence of cases than the U.S., but the rates exceed those in such countries as Sweden and Denmark.

  2. These same folks take it on with the CDC SIR reporting methodology here:

    1. Is this a good thing or a bad thing. Try to find out or figure out how many inpatient cases of CLABSIs, CAUTIs, and SSIs happened annually. Say for 2008 to 2012... Can you do it? I don't think you can. Is this a good thing?

  3. I also found the AAC commentary remarkably simplistic and naive. No one really has any idea why such dramatic differences exist in epidemiology of MRSA between northern Europe and the U.S., but the differences are not limited to incidence in hospitals -- there are also major differences in demographics, culture and circulating MRSA strain types, not to mention vastly different models of health care. It seems to me that the introduction of ADI would not likely make a major difference in the overall epidemiology of MRSA in the U.S. at this point. However, it is hard to argue that latitude correlates well with incidence of MRSA infections given that perhaps the highest incidence of MRSA infections ever recorded was in the far north of Canada: Golding GR, et al. High rates of Staphylococcus aureus USA400 infection, Northern Canada. Emerg Infect Dis. 2011 Apr;17(4):722-5.

    1. Thanks for your comments. My mention of latitude was an attempt to say that there are big differences between each region. If seasonal variation exists in S. aureus epidemiology, it follows that climate could play a role, but this needs to be better defined and wouldn't completely correlate with latitude. As far as transmission and rates seen in the Golding paper, you can't exclude latitude or climate as factors. Since we think of transmission in terms of Ro, it is still possible that given a lower Ro in more northern climates, you could still see big outbreaks.

      the Golding study does also emphasize the importance of strain types given that it was a USA400 outbreak and perhaps there are other differences associated with those remote populations in terms of genetically influenced immune differences. So much is unknown.

      But it isn't all the swabbing.

  4. The people in the Netherlands think they know why their mrsa rates are lower than that of nearby countries. Do you guys know more why about their rates are low than they do?

    Little research has been done to compare the prevalence of MRSA in different
    countries. As indicated above, comparison is possible only if similar principles
    are applied in the collection of data in the various countries. One exception to the
    general picture is the European Antimicrobial Resistance Surveillance System
    (EARSS), which does support proper international comparison. Nevertheless, the
    EARSS database does have the drawback that it relates only to invasive infections,
    in the context of which S. aureus has been cultivated from blood samples.
    The most recent data are from 2004, when more than 27 000 samples of S. aureus
    from infected blood were analysed.34,39 The analysis found that, in 2004, the percentage
    of the infections attributable to MRSA varied from 0.5 per cent in Iceland
    to 56.4 per cent in Malta. In the Netherlands, the figure for 2004 was 1.1 per
    cent. The other countries with MRSA rates below 2 per cent were Denmark,
    Sweden and Norway. Those where MRSA accounted for more than 40 per cent
    of S. aureus blood infections in 2004 were the UK, Malta, Greece, Portugal,
    Romania and Ireland. Although bacteraemia is the tip of the iceberg, the figures
    do show that MRSA is much less of a problem in the Netherlands than in most
    other countries.
    Even in our neighbours Germany and Belgium, MRSA rates are much higher
    than in the Netherlands, at 19.4 and 33.3 per cent, respectively.

    From the report: "MRSA policy in the Netherlands". Highly Googleable...


Post a Comment

Thanks for submitting your comment to the Controversies blog. To reduce spam, all comments will be reviewed by the blog moderator prior to publishing. However, all legitimate comments will be published, whether they agree with or oppose the content of the post.

Most Read Posts (Last 30 Days)