Thursday, February 28, 2013

CREATE-ing an opportunity

I can’t count the number of times we’ve pined for increased funding of healthcare-associated infection prevention research. I’m happy to say that Eli is putting more “money where his mouth is” in this regard, having just received a $4.2 million, five year grant to investigate MRSA infection prevention approaches. This VA HSR&D grant was part of the “Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE)” initiative. Much like the NIH PPG, the CREATE grants fund several (in this case four) major projects that are interrelated along a common theme.

So, a CREATE grant now creates a great opportunity for Eli and his colleagues to advance the science of MRSA prevention. Among the principal and co-investigators in this multicenter partnership are Heather Reisinger, Marin Schweizer, Mark Vander Weg (all in Iowa City), Mike Rubin (Salt Lake City), Luci Leykum (San Antonio) and Dan Morgan (Baltimore).

Congratulations—now, of course, the work begins!

Extranasal MRSA Colonization

Medical decision makers LOVE a good systematic review.  This is especially true if that review synthesizes the literature surrounding a key parameter input for their decision models. Sometimes these studies can even have clinical importance beyond informing decision-analytic models, which is the case here.

In the February 2013 ICHE, James McKinnell and colleagues completed a systematic review that estimated the incremental benefits of testing for MRSA colonization at extra-nasal sites. They combed 4,381 abstracts and 735 articles to find 23 high-quality studies comparing any-site (extranasal+nasal) screening to nasal screening for MRSA. The specifics are outlined in Table 2 below, while the overall message is that an additional one-third of patients will be detected if extranasal sites are screened. What this means as far as changing practice and the cost-effectiveness of adding extranasal sites to screening algorithms will have to wait for those future pesky decision-analytic models. Stay tuned!

Reference: Quantifying the Impact of Extranasal Testing of Body Sites for Methicillin-Resistant Staphylococcus Aureus Colonization at the Time of Hospital or Intensive Care Unit Admission James A. McKinnell, MD; Susan S. Huang, MD, MPH; Samantha J. Eells, MPH; Eric Cui, BS; Loren G. Miller, MD, MPH Infection Control and Hospital Epidemiology , Vol. 34, No. 2 (February 2013), pp. 161-170

Saturday, February 23, 2013

My new white coat is a cool black vest

Those of you who have followed our blog for the past few years probably know that one of my favorite topics in infection prevention is the role of clothing in transmission of pathogens. But I'm also fascinated by the sociologic aspects of clothing in medicine, which is usually framed around questions of professionalism (for example, is a doctor in a white coat more "professional" than a doctor wearing scrubs?). So I was interested to see another paper on this topic in JAMA Internal Medicine (the journal formerly known as Archives of Internal Medicine). The study was a survey of family members of ICU patients in three Canadian ICUs. Over three hundred persons viewed photographs of physicians dressed in scrubs, business suits, white coats with neckties, or blue jeans. The study subjects were then asked to match the variously dressed doctors with certain attributes. In a nutshell, they found that families deemed the doctors in white coats to be most knowledgable, most honest, and best overall. Doctors in scrubs and white coats were deemed equally most competent and most caring.

I'm always amused by these studies because I've never met a patient who chose their doctor on a sartorial basis. It would be like buying a red car because you love that color even though you know nothing else about the car and never took it for a test drive. These types of studies, in my opinion, sell patients short. Yes, all of us form rapid first opinions about those we encounter, but almost all of us are sophisticated enough to quickly move past superficial qualities to assess a person's honesty, ability to communicate, and for physicians, his/her ability to demonstrate empathy. Lastly, the entire premise of the study seems strange--while you might choose your primary care doctor, it's extremely unlikely that you will choose your intensivist. The accompanying editorial is congruent with my line of thinking and concludes that professional behavior is far more important to patients and families than professional appearance.

I stopped wearing a white coat a decade ago, but many physicians still cling to it. Some wear them for storage, which my wife (also a doctor) tells me is more important for women since their clothing has fewer pockets. Some wear white coats as a form of identification, which may have held true when doctors were the only people in the hospital wearing them. Some wear them for warmth. And some just need the ego boost.

I was an early adopter of bare below the elbows and have only worn scrubs when seeing inpatients for the last five years. Smart phones and cargo scrub pants have taken care of my storage needs. But the one downside of scrubs is feeling cold in the winter. My partners and I recently solved that problem. We found vests that are lined but are constructed of nylon on the exterior surface, which allows them to be easily wiped down. They fit snugly so they don't drape onto the patient when performing an exam. And yes, they are warm! I'd like to take credit for the idea, but actually we copied our intensivists, most of whom are also bare below the elbows.

On April 1, we embark on a new policy at my hospital that no longer requires contact precautions for patients with MRSA and VRE. As we educate our staff on the change, we're reminding them that it's ok to shed the white coat and tie. If we're not going to wrap ourselves in plastic, bare below the elbows seems even more important.

Friday, February 22, 2013

We’re doing it wrong—influenza vaccine edition

This prospective cohort study out of University of Michigan demonstrated that influenza vaccine didn’t protect against PCR-documented influenza illness, influenza transmission in households, or medically-attended influenza. Given the good match between vaccine and circulating viruses during the 2010-11 season, and given that the population studied was predominantly healthy young adults and children, these results are pretty shocking (even in the context of other underwhelming data on the effectiveness of influenza vaccination). As John Treanor and Peter Szilagyi opine in the excellent accompanying editorial, “the apparent failure of influenza vaccine under optimal conditions seen in this study is indeed troubling.”

One of the more intriguing findings of this study is that receipt of flu vaccine the previous year seemed to reduce the effectiveness of the vaccine, a finding that is not new. What struck me most after reading these two papers, though, was this statement in the editorial:
"It is frequently stated that evaluation of influenza vaccines in randomized controlled trials is “unethical”, but given that the effectiveness of the vaccine is unclear, the subjects in such studies are typically at extremely low risk of serious disease, and that effective antiviral therapy is available, perhaps this statement should be reconsidered."
When a vaccine’s effectiveness causes experts to consider a return to randomized controlled trials, it’s safe to say that the vaccine in question is pretty awful. We desperately need something better.

Thursday, February 21, 2013

Alcohol Hand Rub Fire?

There is a very sad report about a fire at an Oregon hospital (OHSU's Doernbecher Children's Hospital) possibly linked to static electricity and alcohol-based hand rub. It appears that an 11 year old girl might have been inducing sparks with her hospital blankets when a fire started on her shirt, causing third degree burns. This is a very infrequent event, but fear of possible fires has led to draconian fire regulations that probably end up harming patients more than the very rare fire.  For example, in a 2003 study by Boyce, none of 798 facilities, covering 1430 hospital-years of observation, reported a dispsenser-related fire. When it's an 11 year old girl that's harmed, there's potential for overreaction. However, I hope this doesn't lead to more limitations in hand rub placement and more hospital-acquired infections and I hope she gets better very soon!

Sources: Huffington Post 2/20/2013 and The Oregonian 2/18/2013

Monday, February 18, 2013

Open access: the train has left the station

More and more scientific research is freely accessible via the Internet. In this guest post, Microbiologist Willem van Schaik welcomes this change.

Earlier this month the Royal Netherlands Academy of Arts and Sciences hosted a meeting in the stately Trippenhuis building on recent developments in the field of open access publishing. In this form of publishing, scientific articles are published online, and can be read at no extra cost by anyone with an Internet connection. How much has the scientific world really been changed by open access?
Until recently, the process of publishing scientific articles followed a well-trodden path. Scientists would write a manuscript describing their finding and then would send this to a journal for publication. This journal then arranged for other scientists to complete peer review of the manuscript and if everything appeared satisfactory, the article was published in the journal. The authors then had to hand away their copyright to the publisher of the journal and finally the publisher only allowed access to the article to institutions that had paid a subscription fee.
This is a particularly successful business model for scientific publishers such as Elsevier, Springer, John Wiley & Sons, Nature Publishing Group and many others. These traditional publishers have profit margins well above 30% and earn approximately $ 2 billion per year.
This situation is clearly unsustainable. Because scientific research is mostly funded by governments (ergo the taxpayers), all over the world, tax revenues are funneled into the pockets of the shareholders of major publishers. To make matters worse, the same taxpayers are not given free access to the results of the research that they helped to fund. This is highly relevant in medical fields where doctors and patients are cut off from important scientific information.
In open access publishing the peer review process is the same as in traditional journals, but the authors of the article have to pay a fee for it to be published; however, upon on-line publication, the article is immediately accessible to everyone. In 2011, 12 percent of scientific articles were published under an open access license and this number continues to increase, especially as governments (in the European Union through the Horizon 2020 program, for example) make it a requirement that the scientific articles that have been funded by public money be made freely accessible to everyone.
Ultimately, almost everyone agrees with the principles of open access, but its interpretation and implementation is not always so easy. First, the cost of a publication in some open access journals can be remarkably high. This is especially true for open-access journals published by for-profit publishers. For example, the journal Cell Reports (published by Elsevier) charges $ 5,000 per published article. Particularly in the social sciences and humanities this much money can be difficult to cough up and this may be one of the reasons why in these fields the number of articles published under open access licenses remains fairly limited.
Some traditional (closed access) journals, allow the authors to pay a fee to make their individual article openly accessible, but in this type of hybrid open access, the researcher actually pays twice: once through the university library fees and once from their own research budget.
Besides commercial publishers, there are also non-profit open-access publishers. Here the publication costs can be significantly lower and can often be waived if the authors do not have sufficient funds to pay for the publication.
The best-known non-profit publisher of scientific articles, the Public Library of Science (PLOS), mainly focuses on the biological and biomedical sciences. PLOS ONE, the largest journal in the PLOS-stable, also publishes articles from other fields, but at relatively low numbers. It seems that open-access train has long since left the station in biomedicine, but in other areas the train is still waiting for passengers! Two exciting recent initiatives are the Open Library of Humanities (a non-profit open access initiative in the social sciences) and PeerJ, which has a revolutionary new publishing model.
But are there still obstacles on the open access train’s tracks? One problem is the explosive growth of so-called predatory open access journals. These journals target gullible scientists with the aim to have them pay their article processing fee with the promise of fast (read: non-existent) peer review. Researchers receive spam from these “journals” on a daily basis. Besides being annoying, the dangers of predatory open access journals should not be overestimated, even if they are almost always easy to recognize as scams. In fact, these journals are not unlike the infamous 419 email scams in which a Nigerian prince promises to park millions of dollars in your bank account. With a healthy dose of skepticism (a trait that should be natural to all scientists), predatory open access journals, just like these email scams, should not be successful.
Some claim that the quality of open access journals is lower than that of traditional journals, because the publisher has a financial interest in publishing as many articles as possible. This is not a valid argument: bona-fide journals (both open and closed access) cannot publish everything that is being sent to them, since these journals would quickly become known as a dumping ground of articles of highly dubious quality, in which no reputable scientist would want to publish. Indeed, several open access journals (eg BMJPLOS Biology and eLife) are already seen as ranking at or near the top of their fields.
The general expectation during the symposium of the Royal Netherlands Academy of Arts and Sciences was that in the coming years, more and more science will be available through open access, because of new regulations by governments and an increased desire of scientists to have their work read by the widest possible audience. In many cases when researchers publish their work in closed access journals, they can already post their manuscripts in freely accessible public databases, like PubMedCentralarXiv or Figshare. In the end, the open access publishing model for the dissemination of scientific knowledge will reduce costs and be more efficient than traditional publishing models, benefiting us all, as scientists and as taxpayers.
Willem van Schaik is an Assistant Professor at the Department of Medical Microbiology of the University Medical Center Utrecht (Utrecht, The Netherlands). His research focuses on the genomics of antibiotic-resistant opportunistic bacteria and the evolution of drug resistance. Willem is an Academic Editor for PLOS ONE. His Google Scholar profile can be found here and his Twitter here.

Friday, February 15, 2013

Happy Friday - 21st Century ID Consults

Many of us went into ID because of the diagnostic challenges of complicated fever work-ups or the occasional excitement of a trop-med case. But we ended up here. Oh, is there a separate billing code for doing discharge summaries for other services?

And if you haven't read Harold Horowitz's NEJM Perspective on Fever of Too-Many Origins yet, it's well worth reading.

Thursday, February 14, 2013

Did Google Flu Trends Miss the Mark This Year?

There is a nice review of how various influenza-like illness surveillance systems performed during the 2012-2013 influenza season by Declan Butler at There is some good news and some bad news. The good news is that the timing of the start and peak of the epidemic appear pretty well-aligned between the three methods. However, it appears that the "Google Flu Trends" peak was much higher than the CDC and "Flu Near You" peaks. Reasons for the possible divergence include timing of non-influenza ILIs in the community, a bad norovirus season and excess media coverage including CDC's alert of a bad/early season in early December 2012.

I think these reasons and others given in the article have a lot of face validity and certainly follow what many were feeling as the epidemic progressed. One thing I haven't seen in the coverage is whether the "peak" count of ILI is all that important. I'm more interested in the timing of the epidemic's beginning and the peak and not so interested in an absolute count. I suspect that the absolute number of infections helps in future years, but the timing is more important in the current year. I hope someone will comment or covertly tell me why the peak amount matters so much. It's not like ILI is the greatest definition anyway.

Another assumption I haven't seen discussed is whether Google Flu Trends actually got it wrong or was it the other methods which missed the mark. When you have an imperfect definition, it's hard to call any of these three methods a gold standard. Any attempt to pick a winner seems a bit arbitrary. If the intent is to match the CDC so rates can be compared from year-to-year, that's one thing. But what if we are burdening ourselves with a suboptimal gold standard. A lot of sunk costs go into any legacy system, but it's at least worth wondering occasionally if the legacy is worth continuing.

Image source:

Tuesday, February 12, 2013

PeerJ and Why Giraffes Have Short Necks

Sometimes in life you need a new perspective. In the entirety of my existence, I've always thought of giraffes as having long necks, and I bet many of you did too. But then PeerJ went live today and suddenly my view of giraffes changed.  Instead of long necks, they're more of a medium neck creature. You see, today I discovered that sauropod dinosaurs had necks 15 meters in length or 6x longer than the world record for giraffes.** And as an aside, I learned what anatomic features enabled them to have such long necks.

And it's not just my perspective on neck length that changed today, it's my perspective on open-access publishing.  Until today, if you wanted to publish in an open-access journal, it would be a high-cost affair. For example, publishing in BMC-Infectious Diseases might cost you $2055/article and publishing in PLoS One might cost you $1350/article. Starting today, you can publish your hard-earned research findings in an open-access, advertising free peer-reviewed journal for .... $99.  And that one-time only $99 "membership" will allow you to publish one article a year.  Of course there's a slight catch. Each author has to pay the $99, so if you have 5 authors, it'll cost you $495. If you usually publish with the same author group, that will be a one-time cost.

We've written frequently about the benefits of open-access publishing including increased readership of your papers and the societal benefits of free access to research findings for our tax-paying funders (thank you tax payers!). There are many perceived barriers to open-access, particularly legacy promotion/tenure committees at universities, but these can be overcome. One real barrier has always been cost, but at $99 or even $495 that barrier is slowly going away. What a nice change in perspective!

For more info see Mike Taylor's post in the Guardian Feb 12, 2013

Image source: wikipedia

COI acknowledgement: I'm an Academic Editor at PeerJ (as is Dan). I'm also a section editor at the open-access journal Antimicrobial Resistance and Infection Control, and was recently named Section Editor for SHEA's journal Infection Control and Hospital Epidemiology.

**Yes, I've seen a sauropod skeleton before but I've never thought of giraffes as having short necks. It's the juxtaposition that was refreshing, like open-access next to $99.

Wednesday, February 6, 2013

Gimme a C! Gimme an H! Gimme….


Regular readers of our blog understand how smitten we are with chlorhexidine gluconate (CHG). For use in lines, dressings and the oropharynx, we have controlled trial data. However, for CHG bathing (a.k.a. “source control”), the data have consisted of quasi (before-after) studies without concurrent control groups. So we take note this week of two multicenter, cluster-randomized crossover trials, one published in NEJM (adult ICUs) and one published in Lancet (pediatric ICUs). Both studies were partially supported by Sage, the manufacturer of the no-rinse 2% CHG wipes used, and both had the same design: randomization to 6 months of daily CHG or nonantimicrobial bathing, followed by 6 months of the opposite. The adult (NEJM) study was interrupted by a several month recall of the CHG cloths, but the investigators handled that problem well (and analyzed the data with and without the interruption data included).

The adult ICU investigators examined the outcomes of healthcare-associated BSI and MRSA/VRE acquisition, finding significant reductions in both during CHG use. I’m most impressed with the CLABSI numbers: a 53% reduction during CHG use (1.6 vs. 3.3 per 1000 cath days). The Lancet (PICU) study is underwhelming by comparison, possibly due to the focus on longer-stay kids and the fact that written informed consent was required (which resulted in many subjects not being included—a waiver of informed consent was obtained from every center in the adult study, resulting in more complete enrollment). The primary outcome in the pediatric study was any bloodstream infection (actually, any positive blood culture)—and by intent-to-treat analysis, the reduction in “bacteremia” (in quotes because some of the positive blood cultures were likely contaminants) was not statistically significant, whereas by “per-protocol” analysis the 33% reduction was significant (3.3 vs. 4.9 per 1000 patient days, p = 0.04). CHG was safe in both studies—no increase in skin reactions, no major adverse events.

A sample of MRSA and VRE were collected and subjected to CHG susceptibility testing in the NEJM study, and the results were what would be expected—but who knows how to interpret CHG MICs anyway?

Now for the caveat, the sobering note, the but, but, but—the impact of CHG was among the gram-positive organisms, almost entirely coagulase-negative staphylococci (the yeast (Candida) findings in the adult study are of interest, but the numbers are small). The table above combines the results of both studies by organism group. Not such an exciting story for the gram negative rods, or for S. aureus, which as we know are the more problematic, virulent bugs.

And to finish, a poorly-constructed haiku about chlorhexidine:
Chlorhexidine can
reduce the infection risk
not for the bad bugs?

Friday, February 1, 2013

Living and breathing = aerosol-generating procedure

Eli, who is busy this week attending ScienceOnline2013, pointed me to this newly published study in Journal of Infectious Diseases on influenza transmission. Werner Bischoff and colleagues at Wake Forest measured influenza virus RNA concentrations in air samples taken between 1-6 feet from influenza-infected patients’ heads during routine care. Among the 61 influenza patients they analyzed, 26 released measurable influenza RNA into room air, and 5 did so in very high concentrations. The figure below, from the paper, shows that small particle aerosols containing influenza RNA could be detected 6 feet from the patient’s head (for 9 patients, at levels exceeding their low estimate for a 50% human infectious dose).

What does this mean? Well, this report confirms that some of our influenza patients (those we’ve previously termed “superspreaders”) expel airborne virus in small particles (capable of long-distance spread) even when they aren’t undergoing an “aerosol-generating procedure”. Life with influenza, for them, is an aerosol-generating procedure.

How to translate this into reduced transmission in healthcare settings is tricky, and Caroline Breese Hall’s commentary is worth reading in this regard. A couple things to keep in mind—these investigators measured RNA, not viable virus. And even if we assume transmissibility from the RNA numbers, only a small number of the 61 influenza patients were high-concentration small-particle aerosol emitters. These data alone don't support making sweeping changes in practice for all patients with influenza-like illness (e.g. N95 masks, negative pressure rooms). The challenge is to learn how to identify potential “high risk emitters” early, or to identify specific settings when practice change is needed (based upon dynamics of the community outbreak, etc.).