2 minutes per day (or, Still beating that dead horse, contact precautions edition)

Regular readers know that we’ve long been posting about the unintended adverse consequences of contact precautions, most recently yesterday with Mike’s post on the added associated costs. A research letter was published online today in JAMA Internal Medicine, reporting results of a time-motion study of interns (using RFID badges) to compare time spent with isolated versus non-isolated patients. You guessed it, the interns visited the isolated patients less often and for shorter periods of time. To quote the authors, “[these] results support a growing body of literature suggesting that contact precautions may impede patient care”. We are long overdue for a rethinking of our use of contact precautions. I’ll end with another quote from the authors, one that nicely sums up the take-home message:

"Further research is needed, both to better define the patient population for whom the benefits of contact isolation outweigh the risks and to develop strategies to ameliorate those risks for those who must be placed into isolation."

$35 a day

A new paper in the American Journal of Infection Control takes a look at the cost of contact precautions. The investigators determined that on average 48 gowns and pairs of gloves are used daily for each isolated patient, and donning and removing the personal protective equipment consumed 43 minutes of time per isolated patient per day. This resulted in a cost of $35 per isolated patient day. In the ICU setting the cost was higher at $42. Of course, this represents a fraction of the true cost since there are many other indirect costs. But it's nice to have at least a ball park figure. I quickly calculated that de-escalating contact precautions at my hospital (i.e., no longer isolating patients with MRSA or VRE unless they have uncontrolled drainage or secretions) results in a cost savings of over $700,000 annually. I need to let my CFO know about that!

Photo: TimesUnion.com

Left to our own devices

The big news today in healthcare-associated infection (HAI) prevention is the publication of the CDC’s Emerging Infections Program (EIP) point prevalence survey of HAIs, which includes burden estimates and an update on the epidemiology of HAIs in the US, circa 2011. Simultaneously, CDC released an update on national and state-level progress in HAI prevention. The CDC’s press release provides the bottom line messaging around these data: (1) we’ve made progress, and (2) we still have a long way to go.

One of the most important messages can be found in the abstract of the EIP point prevalence survey paper: 

“Device-associated infections (i.e., central-catheter–associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia), which have traditionally been the focus of programs to prevent health care–associated infections, accounted for 25.6% of such infections.”

The device associated infections (DAIs), particularly CLABSI, are also the HAIs for which the most progress has been made in prevention. Why? Because we have prevention approaches that have been tested and implemented in most US hospitals. A common theme around the remainder of infections (now the great majority of HAIs) is that we have far less understanding about how exactly to prevent them (case in point: non-ventilator associated healthcare-associated pneumonia). 

If we expect to see further substantial reductions in HAIs, we’ll need more funding to support prevention studies for HAIs that aren’t device-associated, and for studies of prevention approaches that address HAIs that are beyond the reach of our rudimentary approaches to DAI prevention (e.g. bloodstream infections sourced to gut or skin in high risk patient populations like burn or bone marrow transplant). 

The assumption that we already know how to prevent most HAIs is patently ridiculous, and over the next few years we will see rates plateau as we gain the maximal benefit from improved hand hygiene and DAI prevention bundles. The next phase of infection prevention will require novel approaches.

My on-again, off-again relationship with the white coat

Silvia Munoz-Price, MD

This is a guest post by Dr. Silvia Munoz-Price, Associate Professor of Clinical Medicine at the University of Miami Miller School of Medicine and Hospital Epidemiologist at Jackson Memorial Hospital.

All the comments after the SHEA attire guidance paper made me reflect a lot, in particular about white coats. So here are my two cents on the topic based on my very personal, and thus very biased experiences.

In a piece like this, I am forced to start with my first conscious experience with white coats, which came from my dad. He would come home –all dressed in white-- after his OB/GYN overnight calls, sit on the sofa with me on his lap and tell me about all his challenging cases. I wanted so badly to be as good of a doctor as he was…but especially, I wanted to look like him…wearing pristine white clothes. Thank you dad for those special moments you shared with me…they were very meaningful.

Let's fast-forward a decade or so to the first clinical rotations in medical school. Wearing the white coat…felt really good. Let’s pause here and give you some context: I did medical school during the nineties in a Latin American inner city public hospital. During my early clinical rotations I had one of my most profound realizations about gender and the medical profession: patients would address any male technician wearing a white coat as a Doctor. Here I come (very young, I admit, less than 20) wearing my white coat. How am I addressed? You guessed right, Miss…which was an accurate description and would have been ok if all my male classmates wearing their white coats wouldn’t have been addressed as Doctors. Those inequalities never ended throughout med school. I thought it was unfair but highly reflective of a male dominated society.

Let's move forward another 5 years, Internal Medicine residency in the US. There are two issues related to attire that I think are worth sharing. One: How often did I launder my white coat? Well, I think it was whenever my sleeves turned disgustingly gray and I could not possibly bear wearing it any longer. Two: nobody ever told me how frequently I was supposed to launder my white coat. While I write this piece I am trying to think if I ever thought the sleeve test was adequate or not…to be honest, I don’t think I ever thought about it. I was too busy and too tired to bother thinking on those alien thoughts.

Fast-forward 5 more years…my period in private practice in the Midwest. It was amazing to me how so few docs wore white coats across the many community hospitals I cross-covered. White coats were substituted by nice—and in some cases, expensive—clothes. During my first year I wore white coats but soon this faded into suits. This is interesting…not wearing a white coat was done by most and accepted by all. No attire guidance, no white coats, no fuss. I am not saying this is right or wrong, after all, it is indeed hard to do hand hygiene with the sleeves of a suit in the way. I just find it interesting how cultural this “white coat” or “no-white coat” phenomenon is.

Another 5 more years: my life in academia. There are at least three points that I frequently reflect on about white coats in this setting:

-One: white coats are a symbol of power. I see this every month in my hospital’s Board Room…towards one side of the table, Department Chairs predominantly males, in their late 50s to early 70s, all wearing impeccable and sparkling white coats (even though many do not see patients any time around that particular meeting)…on the other side, hospital administrators wearing suits. Interesting dynamics. Why do Chairs feel compelled to wear white coats to a meeting if there are no patients around? I understand that some medical professionals think that white coats provide reassurance to patients…but who gets reassurance with white coats in a board meeting? Themselves!

-Two: As an attending in academia, wearing white coats serves as a gender (and maybe age) equalizer.[I think the same might happen with suits in private practice. This is hard for me to explain, so let me give an example and I will let you make your own conclusions. Imagine you are a consultant that comes to a particular hospital rather infrequently. Imagine a fifty-year old male comes into the unit wearing a white coat. Who do you think he is? Probably a doctor. Now imagine a fifty-year old female comes into the same unit wearing the same white coat. Now what do you think? Probably also a doctor. Now, lets get rid of the white coats and put a suit on the male and a dress on the female. What would you think now? Responses will be less homogeneous this time, but whatever you argue would be strongly influenced by your social context and your own personal experiences. White coats are indeed powerful symbols; unfortunately, they do not fully equalize genders. As an example, let me share with you what happened to me a few days ago despite wearing a white coat… here comes a cute old Hispanic lady … “Señorita [Miss], how do I get to 7East?” Yes, sadly, even now in my late thirties and with a second doctoral degree…that continues to happen…but…does it matter? Should it matter? Should I even put any thought into the way family members or families perceive me?

-Three: During 2010-2012 I did a couple of studies looking at contamination of attire. We found that white coats were more contaminated than scrubs and that hand contamination was associated with contamination of white coats, but not with scrubs. Also, in a survey among our providers we found that scrubs were laundered daily but white coats were laundered in average every 2 weeks. This was interesting as nobody had told providers how frequently to launder either piece, but they spontaneously performed laundering with different frequencies on these two types of attires. Why? One is in intimate contact with our skin [scrubs] and the other one is not [white coats]. One has to do with our individual comfort and protection [scrubs], and the other one is mostly in contact with patient’s surfaces [white coats]. The reason why this differential behavior occurs is so far unexplored. Regardless, I decided to start the trend at my hospital to wear scrubs and forego white coats for my teams and me. This lasted about a year and ended as we were writing the SHEA attire guidance, as I decided that I wasn’t going to agree to one thing in that publication and do something else in real life. I have to admit that I really enjoyed being able to wear the white coat again…being able to look and to feel like a real doctor again…and to blend in with my colleagues in academia. My fellows were ecstatic because now they would be able to carry all their stuff in their white coats.

I think the SHEA attire guidance paper had a measured approach to white coats. Even though there is no hard data that attire contributes to horizontal transmission of bacteria, we still felt that there was a need to provide some guidance on how frequently to launder our attire. A minimum of once a week sounded like a good compromise (I wanted this to be a minimum of 3 times a week!!). Regardless, I think this guidance is very helpful, as somebody needed to establish a minimum laundering frequency so that the sleeve test stops occurring.

White coats…such strong symbols of who we are…they not only reassure patients…they reassure us, physicians. Look inside of you…do you think white coats might be hiding some of your own personal and professional insecurities? To some degree…yes. Some of the passionate reactions against the attire guidance paper seem to indicate so. But, we should all be clear that when we discuss white coats, we are not doing this because of infection control reasons. If we used an infection control rationale solely, then there wouldn’t be any use for white coats, as they do not protect patients or providers, I would argue that it is the opposite for patients (we just haven’t proved this yet). Culture, social context, age, gender, and perception… these are all issues tied to white coats.

Let me end this piece with something that happened a week ago in the Board Room. That day I was already writing this piece. The room, as usual, was filled with white coats or suits, and had a marked older male predominance. I was sitting to the side pondering about these thoughts, wearing a white blouse and a red pencil skirt, getting ready to address the crowd. How will this crowd perceive me? A relatively young, Latin physician with an accent…would this perception be different if I were wearing a white coat just like them? And most importantly…should this matter? As I approached the podium and gave them my Infection Control update…I can honestly say that I felt fully confident on what I was saying and how I looked, of what I had accomplished so far, and of all the wonderful things I will accomplish in the future…and all this happened without wearing a white coat.

What we talk about when we talk about MDR-GNR

I’m supposed to give a talk at SHEA 2014 on “Lab Identification and Surveillance for Multidrug-Resistant Organisms” (that title is a real barn-burner, right?). I dashed off material on MRSA and VRE pretty quickly, but got bogged down fast when I hit the category of “multidrug-resistant gram negative rods (MDR-GNR)”. Why? Two major reasons: (1) MDR-GNRs encompass a vast array of different species, each with its own bag of tricks, and (2) most labs are underprepared to accurately detect and characterize the most fearsome of the MDR-GNRs (e.g. carbapenemase-producing Enterobacteriaceae (CRE)). Therefore, it is a major challenge to even define what we are talking about when we talk about MDR-GNRs.

One of the articles in the current special issue of Infection Control and Hospital Epidemiology drives this point home nicely. In a survey of hospitals in the SHEA Research Network, Marci Drees and colleagues tallied 14 unique definitions for MDR-Acinetobacter, 18 for MDR-Pseudomonas, and 22 for MDR-Enterobacteriaceae (that’s a lot of definitions for just 66 responding hospitals!). There was similar variation in what these hospitals did when MDR-GNRs were identified (isolation practices, cohorting, etc.), and in how equipped laboratories were to find the organisms of greatest interest (e.g. CRE). This isn’t an indictment of the hospitals or their labs, it simply reflects the fact that drug-resistance among gram-negative organisms is extraordinarily complex, and the molecular methods needed to rapidly characterize the most troublesome organisms are beyond the reach of most clinical labs.

In the absence of affordable commercial methods for detection of common MDR-GNR resistance mechanisms, we desperately need to develop a network of specialized regional referral labs that can quickly characterize pathogens submitted from clinical laboratories. Whole-genome sequencing could be introduced in such labs as a first step to wider adoption and development of automated data interpretation software. Let’s hope that the $30 million CDC budget allocation for responding to antibiotic resistance will move us in that direction.

Image from Wikipedia Commons

No spring break for measles

If you’re a regular reader, you may have noticed the blog has been on break for a little while. While I was trying to relax with my morning coffee last week in Sarasota, I kept running across reports of measles outbreaks in New York City, British Columbia, and California. As usual, these outbreaks can be sourced to those who refuse immunizations, perhaps because of long-discredited fears about autism, or (as in the case of the BC outbreak) because they are getting confusing messages from the person who speaks for their deity. 

I have nothing to add to this commentary by a New England pediatrician, which refers to a depressing study out of Dartmouth that suggests our current messaging around vaccine acceptance is ineffective. For a great recent example of good messaging, see this post by Tara Smith, entitled, “Why I vaccinate my kids”.

But if factual, rational messages fail to sway vaccine deniers, what other options are available? How to respond, for example, to those who base their vaccine denial on religion? So I spent the better part of my time away in prayer and meditation, seeking revelations from all the major deities. I’m happy to announce that they all were in favor of immunization. The main point each of them made to me (aside from pointing out that all the others I communicated with were false deities, not worthy of my time), was that they gave humans an astonishing intelligence and reasoning capacity for a purpose. 

Thus I implore you to go forth and get immunized. The only true god of your choice commands it.

Antimicrobial overuse: A tragedy of the commons?

The CDC just released a report on antimicrobial use practices in U.S. hospitals that confirms what many already suspect: antibiotics are overused and/or used incorrectly a large percentage of the time. The details are summarized in the MMWR report and accompanying Vital Signs. 

Eli just posted on our post-antibiotic era, and we will undoubtedly have more to say about this later—for now, though, I’ll outsource to this excellent commentary by Scott Flanders and Sanjay Saint in JAMA Internal Medicine. I have a minor quibble with any construction of this problem as a kind of “tragedy of the commons”, where rational decisions to improve individual health run counter to the interests of society. Inappropriate or unnecessary antibiotic use hurts both the treated individual and society. Moreover, the most persuasive arguments for improving antibiotic use are those that appeal to improving individual patient outcomes (rather than to saving money or reducing resistance rates in aggregate).

Finally, the clinical microbiologist in me can't help but emphasize one of the greatest obstacles to optimizing antimicrobial therapy: the absence of rapid and accurate diagnostics. On that note, here is some bedtime reading.

Staphylococcus aureus: Here, there and everywhere

To spend any time on our infectious diseases consult service is to be knee-deep in invasive, difficult-to-treat S. aureus disease. Most S. aureus (including MRSA) disease is caused by a strain previously colonizing the host, and given that up to a third of the human population carries S. aureus it is easy to understand why the disease is so common. Exposure to healthcare is a major risk factor for invasive S. aureus disease, simply because so many healthcare interventions (surgery, device use, antibiotic exposure) provide opportunities for the organism to invade. 

Nonetheless, the conventional wisdom still holds that a large proportion of healthcare-associated S. aureus disease results from patient-to-patient transmission events—the corollary being that prevention of S. aureus disease should focus primarily on preventing transmission (including active detection and isolation). However, a careful assessment may demonstrate that interventions solely designed to interrupt transmission are responsible for only a small portion of disease reduction in observational studies (for an example, see my previous post on the VA MRSA directive). This is important, as it should focus our attention on preventing disease among those at risk for colonization (everyone), via such horizontal measures as device-associated infection prevention bundles, chlorhexidine bathing, and suppression/eradication of the carrier state during high-risk intervals. 

A study by UK investigators published in Clinical Infectious Diseases provides further evidence that patient-to-patient S. aureus transmission is a relatively uncommon event, even as an explanation for S. aureus “acquisition” events in the ICU. Using whole genome sequencing (WGS), the investigators found that only 7 of 37 ICU patients who “newly acquired” S. aureus were colonized with strains that were closely related to other patients who had an overlapping ICU stay. There are several limitations to the work, most of which are outlined by the authors in their discussion and by the excellent accompanying editorial by David and Daum. The limitation most concerning to me is the assumption that a single nares + perineum culture plated directly to solid agar media (chromogenic agar and Columbia CNA) is a sensitive method for detection of S. aureus carriers. It isn’t. Failure to perform a throat culture or to use broth enrichment probably reduced sensitivity by 30-50% (explaining their overall carriage rate of only 16.7%, when most published studies demonstrate S. aureus colonization rates of closer to 30%). We recently performed a study wherein we cultured 500 pregnant women at 5 body sites—the table below is taken from our presentation at the Decennial meeting in 2010 in Atlanta. The bottom line? Using only nares and perineal cultures directly plated to solid agar media would have missed more than half of our S. aureus carriers. Achieving 90% sensitivity (using a positive culture at any of the five body sites as the gold standard) required sampling both the nares and the throat and using overnight broth enrichment.

So what about all those “acquirers” carrying isolates that didn’t match other ICU patients? In addition to implicating other potential reservoirs (personnel, visitors, etc.), I’d wager that some were prior carriers who were newly detected due to sampling issues, increase in CFU associated with healthcare exposure, etc. Intermittent detection of S. aureus carriage is well described, and would be magnified using the microbiological techniques in this study.

Finally, while I agree with the authors that WGS is the new gold standard for assessing genetic relatedness, the use of spa typing as the “conventional method” comparator is too easy. As we found in our recently published study, roughly half of all MRSA isolated from epidemiologically unrelated clinical infections in 43 US hospitals were from a single spa type! (How’s that for discriminatory power?) If you’re going to write off the conventional methods, at least use a method with better discrimination, such as PFGE!

We're in the post-antibiotic age

We're so very lucky to have lived in the "age of antibiotics."  However, most of us were neither alive nor cognizant prior to 1943, so we don't have a concept of the morbidity and mortality prevented by antibiotics. In some regards, this pre-1943 period is the future we're facing.  Author and science journalist Maryn McKenna has a wonderful article up on medium.com where she discusses this post-antibiotic past and future using a touching story of her great uncle along with facts such as "one out of every six recipients of new hip joints would die" without antibiotics. She also discussed this article on yesterday's CBC "Sunday Edition" radio broadcast (audio available here).

As if we need other things to add to our phobia lists, there's a new case-report published in JAC last Friday of an elderly Spanish woman with chronic renal disease and recurrent UTIs. She initially presented with pyelonephritis caused by a susceptible E coli. However, after 1 week of therapy she developed sepsis and renal failure that was unresponsive to meropenem and died. MDR E Coli was isolated, which was resistant to all tested antibiotics except fosfomycin, tigecycline and tetracycline. Further analysis identified numerous resistance and virulence genes (see figure above). Importantly, the authors state that this is "the first report of the co-production of KPC-3, VIM-1, SHV-12, OXA-9 and CMY-2 in a unique clinical multiresistant E. coli isolate."

With air pollution, it's risky to breathe and with water pollution it's risky to drink. I guess now it's risky to pee.

h/t Christina Vandenbroucke-Grauls