Antimicrobial Stewardship: The President, PCAST and Beyond

There's been a lot of excitement the past couple of weeks surrounding the release of several overlapping documents: the PCAST Report, the National Strategy for Combating Antibiotic Resistant Bacteria, and the President's "Combating Antibiotic-Resistant Bacteria" Executive Order. The Order is interesting in that the effort is to be coordinated by the National Security Council staff and guided by a task force co-chaired by the Secretaries of Defense, Agriculture and HHS. By next February 15th, The Task Force is to submit a 5-year National Action Plan and The Secretary of HHS is to establish a Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria. The additional components include improved antimicrobial stewardship, promoting novel antibiotic and diagnostic discovery, strengthening national surveillance, and finally preventing outbreaks and transmission through identifying and evaluating additional strategies in the healthcare and community settings for the effective prevention and control of antibiotic-resistant infections. Woo woo! Infection Control was mentioned!

The primary focus of the Executive Order and related reports, if you go by length and depth of recommendations, is antimicrobial stewardship. The orders include: (1) requiring hospitals (including DOD and VA) and other inpatient healthcare delivery facilities to implement robust antibiotic stewardship programs (2) monitoring stewardship through NHSN (3) encouraging USDA, FDA and EPA to continue efforts to reduce antimicrobial use in animals. I encourage you to read all three documents.

One of the best reasons to blog is that it forces you to read the literature, so when I finished reading the PCAST report, I grabbed the latest issue of JAMA. Toward the end of the issue there is a Clinical Challenge case of a 32-year-old man with recent travel to Venezuela and a skin and soft tissue infection. Without giving away the case (although the diagnosis is obvious), I wanted to highlight the fact that the proper diagnosis was missed by 10 clinicians "who collectively prescribed oral amoxicillin, cefadroxil, cephalexin, azithromycin, clindamycin, and cefdinir as well as intramuscular ceftriaxone and topical bacitracin, mupirocin, and polymyxin B." Of course, since the diagnosis was missed by all 10, none of these treatments had any effect. Thus, all of these antibiotics were unnecessary and when multiplied by the thousands of cases just like it that occur every single day, you get a sense of the scope of the antimicrobial overuse/misuse problem.

Now, this is just one random case but I think it highlights several major challenges facing antimicrobial stewardship. First, it shows that proper diagnosis requires proper training in infectious diseases and not just new diagnostics. Given that infectious diseases is a specialty in decline, it is likely that proper training in the recognition of infectious syndromes will not exist in the future. No new PCR test would have helped this poor patient since none of the clinicians thought to order the existing PCR in the first place. Second, medical students, residents and fellows are not adequately trained in antimicrobial prescribing. They can't learn how to prescribe antibiotics after a few (non-standardized lectures) and without the supervision of ID physicians (since they won't exist in the near future) during their clinical rotations. It has gotten so bad for the field of infectious diseases that many antimicrobial stewardship programs are now managed by non-ID clinicians.

So here are my recommendations for what needs to be included in the next Action Plan:

1) Improved reimbursement for Infectious Disease clinical activities since the major reason residents are choosing not to do an additional 2-3 years in ID fellowship training is that the additional training actually LOWERS their salary compared to non-ID boarded hospitalists

2) Increased funding for ID training programs

3) Federal support for a 3rd year ID fellowship (after the 2-year clinical fellowship) in either Hospital Epidemiology, Antimicrobial Stewardship or both

4) Increased research funding to identify barriers to infection control and proper antibiotic prescribing and interventions to improve both

The Reports last week were an amazing step. However, it will not be enough to have antimicrobial stewardship programs without infectious diseases physicians available to guide their implementation and train the next generation of non-ID clinicians. And of course, without the proper science guiding the selection and implementation of interventions, stewardship and infection prevention programs will have limited utility. A long way to go, but exciting to finally get started.



image source: recent Field Museum (Chicago) Exhibit

Welcome back to Iowa, Mike!

There has been so much going on lately—a tragic Ebola outbreak, the spread of EV-68, the release of the PCAST report—that we’ve simply not been able to keep up on the blogging front. We do have day jobs, after all, which brings me to the point of this post: welcoming Mike Edmond back to Iowa, where he’s now Chief Quality Officer at the University of Iowa Hospitals and Clinics. 

Mike and I trained together at Iowa two decades ago, and 5 years ago we decided to start this blog as a way to provide timely opinions about current controversies in hospital infection prevention. One of my first posts referenced a JAMA editorial penned by Eli Perencevich, and within the year Eli had settled in at Iowa and joined the blog. 

I guess this site has some kind of gravitational pull, because we’re now all colleagues here in Iowa City. Although Iowa City is the center of the universe, we’re aware that we need to solicit guest posts from elsewhere to prevent our blog from becoming, well, too corny. So please, if you have something you wish to get off your chest about HAI prevention, feel free to email one of us about contributing a guest post.

One advantage of hiring Mike, I should point out, is that we’re saving money on white coats—the image below is a requisition that I signed earlier today, as the ID division director at Iowa. Once I noticed what the requisition was for, I quickly cancelled it, knowing how Mike feels about the white coat….

Enterovirus 68 in 38 States

Yesterday, CDC released updated statistics that describe the emergence of EV-D68 in the US. Last month the virus appeared in Missouri and Illinois but quickly spread with 226 confirmed cases now in 38 states. Clearly these numbers underestimate the extent of EV-D68 illness since most hospitals are unable to test for this virus and once it's confirmed in a region, additional testing provides few benefits.

The NY Times reported that the University of Chicago Medicine Comer Children’s Hospital had to go on diversion three times in the last month because their emergency department was filled with children suffering from acute respiratory illnesses. Prior to this outbreak, they hadn't diverted ambulances in 10 years. It is possible that other viruses are contributing to the problem; however, CDC reports that of the specimens sent to their lab about half were EV-D68 positive and a third were positive for other enterovirus or rhinovirus strains.

The NYT article also mentioned that Children’s Hospital Colorado saw ~3,600 children in the past month with approximately 10% requiring hospitalization. Christine Nyquest, the hospital epidemiologist quoted in the article, stated that her hospital was facing a bed crunch and having difficulty maintain adequate supplies of albuterol.

Overprotection Does Not Equal Protection: Ebola and Healthcare Worker Deaths

There is a disturbing, if not surprising, post in Bloomberg describing the horrible conditions that healthcare workers face when caring for patients with Ebola. In the current outbreak it is estimated that over 300 healthcare workers have been infected and 150 have died. It is clear that the systems designed to protect healthcare workers are failing. The central problem is that the temperatures inside the "Ebola Suits" can reach 115 degrees and can take a long time to safely remove. To begin to understand the problem, all you have to do is read this quote from Douglas Lyon:

“The first 15 minutes I was just hot...After that I was hot and had a wicked headache. Each breath in was a mix of a hint of cool relief and the feeling of suffocation. Each breath out was as warm and hot and humid as the rest of you.”

How long can you wear such a suit? How carefully will you remove such a suit? I suspect that it's hard to be deliberately slow when you're suffocating. On top of that, these suits are expensive. A facility caring for 70 patients is estimated to go through 200 sets of protective equipment per day at $77 each - $15,400. This is in countries where they can't normally afford to purchase alcohol hand rub, so hospitals distill it themselves from sugar cane or other sources.

The suffering and cost would be fine if bodysuits were both effective and necessary; however, this might not be the case. Our co-blogger Dan and colleagues wrote a wonderful opinion in the Annals last month that highlighted CDC recommendations: contact and droplet precautions - a fluid-impermeable gown, gloves, a surgical mask, and either goggles or a face shield along with shoe/leg coverings if the patient has “copious” secretions and N95 mask if they are undergoing an aerosol-generating procedure.

CDC does not recommend full-body HazMat suits.

Apart from asking you to read the paragraph below and suggesting that if we had better science around infection prevention, we'd have safer hospitals and less debate around things like HazMat suits, I would like to close with a quote from the Annals commentary: "Exceeding these recommendations may paradoxically increase risk. Introducing new and unfamiliar forms of personal protective equipment could lead to self-contamination during removal of such gear. Requiring HazMat suits and respirators will probably decrease the frequency of provider–patient contacts, inhibit providers' ability to examine patients, and curtail the use of diagnostic tests...Using extra gear inflates patients' and caregivers' anxiety levels, increases costs, and wastes valuable resources."

-----

Usually, when I'm frustrated about the lack of science around infection prevention, I end my post by requesting adequate research funding. What is entirely obvious is that we take infection prevention for granted. We know hand hygiene should be 100% and we have gloves, gowns, masks, bodysuits, yet we fund NO research on how to improve hand hygiene compliance, develop better gloves or design new bodysuits that clinicians can remove safely. We are now paying a price for this lack of attention. I hope that federal agencies or the Gates Foundation will fund infection prevention studies that determine ways to improve systems of prevention so that caring for patients with Ebola isn't life threatening and so we no longer transmit deadly pathogens in our hospitals.

If ever there were a saint...

Here's an interview with an amazing and brave woman, Cokie van der Velde, on the front lines of the Ebola epidemic--it's scary, sad, hopeful and humbling.

Photo:  Nichole Sobecki, BBC News

The Ebola War

Things are just awful in Liberia, and getting worse elsewhere as well. The problem now clearly outpaces the response, resulting in shortages of everything from barrier protection to hospital beds. Worse, there is a breakdown in civil order and trust that makes it impossible to do the hard work of case identification, contact tracing and education--which is what ultimately brings epidemics under control. 

The latest, and somewhat controversial, call is for a large-scale military or quasi-military response to the outbreak. Although there are clearly downsides, experts from Peter Piot to MSF leaders to Mike Osterholm are calling for military involvement. 

The need for such involvement is based simply on the scale of this disaster—WHO, CDC, non-governmental groups like MSF, no group has anything close to the logistical capability of the military to quickly deploy personnel and supplies almost anywhere in the world. If, as MSF suggests, military assets are “not…used for quarantine, containment, or crowd control measures”, which have backfired (particularly in Liberia), such a response could help bring essential capacity where it is needed most. The chart below provides a comparison of the total budgets for the US military, CDC, WHO and MSF. I realize that the military is not designed for infectious diseases outbreak response, but we’ve invested in a massive military complex (to the exclusion of investment in many other areas, including infectious diseases prevention), so I’m not sure we have any choice: the United Nations to coordinate, UN member nations' military assets to move materials and people, and the CDC, WHO, MSF and others to provide expertise.

Top Papers in Infection Prevention

Last week, Andreas Voss gave a talk on the year's top papers in infection prevention at ICAAC. He graciously allowed us to post his slides to the blog. To see his presentation, click here. Thanks, Andreas!

Ebola: Could it get worse?

Today's New York Times OpEd section has a provocative and scary piece by Mike Osterholm. It focuses on the possibility that mutations in the Ebola virus could allow the virus to spread via the airborne route. I must admit that I don't know enough virology to comment on the probability of that occurring, but it is sobering to think about the implications of this. He also offers some recommendations for improving the management of the current epidemic.

Image:  Jonathon Rosen, New York Times

Donning and Doffing

Many have spent the last month or so preparing for possible patients with Ebola. Last week I had the opportunity to review the tremendous amount of work that the UIHC infection preventionists have completed towards our preparation. During this process, I watched these videos prepared by the Biocontainment Unit at the Nebraska Medical Center that demonstrate the proper use of Biological Level C PPE. My thoughts when viewing these are that without significant practice, it would be very difficult to prevent contaminating or breaking protocol when removing this level of PPE and that donning and doffing take almost 14 minutes. That's a bit more time than hand hygiene - so no more complaints about that! And thanks to Nebraska for sharing these well-prepared videos.

Donning:


Doffing:

Where did all the pediatric HAIs go?

In keeping with the pediatric theme this week, there is a nice study just published in Pediatrics outlining the general trends in Pediatric HAIs between 2007 and 2012. Stephen Patrick and colleagues from Vanderbilt and Boston Children's Hospital used CDC NHSN data from 173 NICUs and 64 PICUs to track CLABSI, VAP and CAUTI rates.

The good news is that CLABSIs declined from 4.9 to 1.5 per 1000 central-line days in the NICU and from 4.7 to 1.0 per 1000 CL-days in the PICU. There were also significant reductions seen in VAP in both NICUs and PICUs. CAUTIs were not adequately reported in NICUs; however, in PICUs the authors found that CAUTI rates did not change significantly over the 6-year study period. I've included the NICU and PICU figures below. Importantly,  CLABSI rates were twice as high and VAP rates were over three times as high in very low birth weight ( < 1500g) infants.

Apart from highlighting recent successes in reducing HAI, I think the main messages (as I've already stated elsewhere) are that HAI are still very common in VLBW infants and that rates remain above zero in all pediatric populations. Thus, despite cultural changes, implementation of insertion bundles and technological innovations, such as antimicrobial-coated catheters, we still need additional evidence-based methods to prevent HAI in children. While we might take this occasion to rest on our laurels and celebrate past successes, we should instead increase funding for development of HAI prevention interventions, particularly in VLBW populations.

And while policymakers might think we can mandate further HAI reductions through such things pay-for-performance, it is clear from these data that those tools have already done their job yet there's much more hard work to do. Notice the almost flat rates in both figures over the past 3-4 years. We need more than quality-improvement goals. Without scientifically proven methods to further reduce HAI, I suspect rates will remain stagnant. That would be unfortunate.

Enterovirus 68: Talking Points

Yesterday, I discussed the recent emergence of EV68 in the US and its association with respiratory illness in children. Naturally, there has been a lot of media interest and parental concern. In addition, CDC released a new MMWR earlier today that describes the two best characterized EV68 outbreaks in Kansas City and Chicago. Of note, the CDC report necessarily describes only the sickest patients with EV68, those admitted to the hospital and tested. Like most viral illnesses, we expect the vast majority of infected children to either not develop symptoms or develop less severe symptoms that might require a visit to a clinic but not require hospitalization. Personally, I have replied to dozens of emails, attended internal meetings and completed several interviews with the media, so I thought I'd share a few general discussion points that have come up more than once today.

For Parents:

1) What is EV68? Enterovirus 68 (EV68) is not a new virus, but over the past few years it has caused outbreaks of respiratory distress in the fall. These outbreaks are similar to what we see later in the year with influenza and RSV. What's different is that this is happening earlier in the fall and with a rarer virus.

2) Who does this virus infect? In the current outbreak, most patients are children under 16 with a prior history of asthma or wheezing. Symptoms include rapid onset of cough, wheezing and difficulty breathing. EV68 rarely causes fever. Most children with suspected EV68 infection respond quickly to supportive care that includes breathing treatments, such as inhalers prescribed by a health care provider.

3) What should I look out for? If your child or family member (or friend) develops rapid onset cough, wheezing or difficulty breathing, please contact their health care provider. While most patients do not require hospitalization, children can develop symptoms rapidly, so a quick call or visit to a health care clinic might be necessary.

4) Is there an antibiotic I can take or a vaccine? No, there are no currently available antiviral medications that treat EV68. There is also no vaccine. However, that does not mean that your child can't be treated. Children with severe respiratory distress can receive several forms of breathing treatments that reduce their symptoms and get them on the road to recovery.

For Hospital Epidemiologists and other Health Care Workers:

1) EV68 is only rarely associated with high fevers. Thus, presence of fever is not an effective question for screening visitors for illness. Thus, facilities currently experiencing an outbreak of EV68 or an uptick in viral respiratory illnesses, should consider restricting access to visitors under the age of 15 or 16 (the oldest confirmed cases in the CDC report). Of course, exceptions should be made in certain situations.

2) HCW who are ill or suspect they might have a viral respiratory illness should follow their hospital policies concerning work attendance. As we've mentioned before, presenteeism (coming to work sick) is a big problem, so avoid it if at all possible.

Disclaimer: This post is not intended to provide specific healthcare advice to an individual patient or healthcare facility. Please contact a doctor or other healthcare provider if you have specific questions about your or your child's health. Also, I will not respond to specific comments asking questions about the care of individual patients. Finally, don't trust any healthcare advice you receive over the internet. Oh, and all of this information will be obsolete and expire by tomorrow.

E is for...Enterovirus 68

Never a dull moment. Just as facilities have begun wrapping up their Ebola preparation plans, there's gathering evidence that several US states may be facing large clusters of acute respiratory illness associated with human enterovirus 68 (EV68).

Last week the Missouri Department of Health released an Alert describing increased cases in St. Louis and an outbreak of over 300 acute respiratory illnesses in a Kansas City pediatric hospital with 15% requiring ICU care. 19 of 22 specimens sent to the CDC from the Kansas City outbreak were positive for EV68. Many St. Louis cases were positive for enterovirus but specific typing is pending. Denver is seeing severe respiratory illness in very young children and children with asthma. Children's Hospital Colorado has treated 900 children and admitted 86 since August 18th, but so far the specific viral pathogen has not been confirmed. CDC reports similar cases have appeared in at least 10 states -- Missouri, Kansas, Illinois, Kentucky, Iowa, Colorado, Ohio, Oklahoma, North Carolina, and Georgia.

There are a few publications over the last 5 years describing EV68 associated outbreaks including an MMWR covering 2008-2010 clusters and individual reports from the EV68 emergence in the Netherlands, and an Indian Health Services (IHS) outbreak in children (both were already covered in MMWR). The Netherlands has seen the majority of cases in September to November (Figure above) with the highest prevalence in patients ages 50-59, while the IHS outbreak occurred in August-September in children with a median age of 4.8 years.

Clinical Findings: Signs and symptoms include cough, tachypnea, hypoxemia, and wheezing, particularly new-onset. In the Arizona IHS outbreak, at least half of the children had infiltrates on CXR and short hospital stays (median 1.5 days). The clinical presentations of the 18 IHS patients are listed in the table below.

Diagnosis: There are commercially available, FDA-approved, multi-pathogen detection systems including Luminex xTAG RVP, Idaho Technologies FilmArray Respiratory Panel. However, these non-specifically identify pathogens as "entero-rhinovirus" or "human rhinovirus/enterovirus." Most facilities can't currently perform enterovirus typing. Identification of EV68 requires partial sequencing of the structural protein genes, VP4-VP2 or VP1.

Treatment: There is no specific treatment for EV68. Care is usually supportive and only a minority of patients require brief hospitalization. Currently, there are no vaccines available.

Infection Prevention: The CDC currently (2007) recommends Standard Precautions for enteroviral infections but recommends "Contact Precautions for diapered or incontinent children for duration of illness and to control institutional outbreaks." However, most of the data that informed these recommendations were not derived from respiratory EV68 outbreaks. Recommendations from Hong Kong are very similar. 

I contacted a hospital epidemiologist in one of the states experiencing an outbreak, who has graciously shared their current protocol. Currently, they use symptoms to drive precautions so their respiratory patients are placed on droplet plus contact isolation for the duration of their hospitalization. In addition, they started their usual winter respiratory visitation restrictions last week so that children under 13 yo cannot visit and increased their focus on year-round routine screening of all visitors/family members for illness. Finally, they noted that this was the earliest they've ever started respiratory visitation restrictions.

Surviving Ebola

Here is an interesting interview with Dr. Kent Brantley, the Ebola survivor, and his medical providers at Emory University Hospital. Key messages in this piece regarding the illness are:

• Diarrhea is very severe (cholera-like)
• Severe electrolyte imbalances result from the massive fluid losses
• Some patients are probably dying of arrhythmias due to the electrolyte disturbances

Photo: TruNews

What do Atlanta GA, Omaha NE, Bethesda MD, and Hamilton MT have in common?

Give up? Each city is home to one of the four biocontainment units in the United States. Dr. Rick Sacra, the obstetrician recently diagnosed with Ebola in Liberia, is being flown right past the University of Massachusetts, where he works, and landing in Omaha to be admitted to the largest of these units. The ten-bed unit has similar capabilities to the smaller such unit at Emory, and has admitted one patient since it opened in 2005 (that patient was ultimately diagnosed with malaria). The video above includes a nice description of the unit from Dr. Phil Smith, a FOTB (friend of the bloggers) who also happens to be a tremendous ID doc and healthcare epidemiologist (trained, of course, at Iowa!). 

The destination of those with confirmed Ebola returning to the US for treatment appears to be decided by the US State Department, and the biocontainment units are their preferred options. An interesting question—if someone is diagnosed with Ebola after admission to another US healthcare facility, how much pressure will there be for them to be transferred to one of these four units?

How transmissible is Ebola? About the same as pandemic flu.

There seems to be very little good news associated with the Ebola epidemic in West Africa. The death toll is now approaching 2,000, and the disease continues to spread. The World Health Organization reports that a lack of resources has hampered its efforts. And we have recently learned that another physician has developed the disease. What's worrisome about his case is that he had no known contact with an Ebola infected patient.

Over the past few weeks, I have read several times that the Ebola virus is not efficiently transmitted. At first glance it seems hard to reconcile that with the reports we are receiving from Africa. So let's look a little closer at this. The basic reproduction number (R0) is a metric that quantifies transmissibility. R0 is defined as the average number of secondary cases generated by a case in a susceptible population. For example, measles, one of the most highly contagious infections, has a R0 of about 15, though it can range from 7 to 29 depending on the study evaluated. Thus, each case of measles would be expected to lead to 15 additional cases in a susceptible population.

A new paper in PLoS uses data from the current outbreak in West Africa to determine transmissibility. The investigators found that the R0 is 1.5 in Guinea, 1.6 in Liberia, and 2.5 in Sierra Leone. To provide some context, it is interesting to look at another paper, published today, which is a systematic view of the literature on the transmissibility of influenza. These investigators report that the R0 during the 1918 influenza pandemic, which killed an estimated 30-50 million people, was 1.8. No one remembers that pandemic, but we do remember the 2009 H1N1 pandemic, for which the R0 was 1.5.

Because Ebola virus is primarily transmitted via direct or indirect contact, as opposed to true airborne transmission, the virus seems to have less of a terrorist effect. That is, Ebola infection has the appearance of a much less random event compared to other infections like influenza or SARS. Sitting in my comfy office in Richmond, I have no reason to fear Ebola. On the other hand if I were working in Liberia, I wouldn't be too comforted by Ebola's relatively low R0. As David Hartley eloquently writes in his blog, "no where is it written that dangerous pathogens must have a high R0."

Photo: CNN

“These go to eleven”, Laboratory Edition

We’ve covered some of the controversial issues around Ebola planning in US hospitals (recognizing that planning meetings in places where Ebola isn’t seem trivial compared with the disaster unfolding where Ebola is). A couple more opinion pieces have come out in the past week, one from The Lancet and one from Annals of Internal Medicine. Despite ongoing disagreements regarding transmissibility, I think most US hospitals will take a similar approach: to ensure that patients don't have to be moved for procedures, and to ensure there is an anteroom for PPE removal, hospitals will identify airborne isolation rooms as their Ebola isolation rooms, and ample PPE will be provided. The major difference will be that some hospitals will routinely use N95s or PAPRs and others will use them only for aerosol-generating procedures. In my view, the most important thing is education, and more education, with 24/7 monitoring of PPE use (including careful doffing procedure).

On the laboratory front, though, I sense a lot more disagreement, and the trend is toward extreme caution. As I’ve pointed out before, the overwhelming majority of those with febrile illness upon return from the outbreak areas will not have Ebola—but they may well have something requiring urgent attention and appropriate therapy (malaria, typhoid, meningococcemia). Prompt laboratory testing will be essential, and potentially life-saving. The CDC guidance provides adequate protection for specimen collection, transport, and handling, while recognizing that “U.S. clinical laboratories can safely handle specimens from these potential Ebola patients by taking all required precautions and practices in the laboratory, specifically designed for pathogens spread in the blood”. A partial list of viral pathogens that may be found in high concentrations in blood we test every day in our labs includes HIV, CMV, EBV, HCV, HBV, parvovirus, HSV and VZV.

However, many hospitals plan not to let any samples from suspected Ebola patients cross the threshold of their laboratories. In addition to doing “minimal testing”, these hospitals plan to purchase point-of-care (POC) instruments so that they can do all testing in (or near) the patient room. This expensive approach could paradoxically increase risk both to the patient (limited test options, quality control, accuracy) and to personnel (requiring training on new instruments with which they may be unfamiliar).

The “point-of-care (POC) plan” is likely to gain even more traction after this report from Emory regarding their approach to testing of their two Ebola patients: 

“…our strategy was to establish a self-contained POC laboratory that could support all requisite testing within the quarantine facility itself and to develop a team of volunteer clinical pathologists and laboratory technical staff with expertise in POC testing who could perform all assays on site.”

This approach, unattainable for most US hospitals, is awkwardly at odds with the CDC’s guidance. The authors recognize this, going on to say:

“Our approach exceeded the requirements of the CDC for safe management of patients infected with Ebola. This description is not intended as a recommendation or endorsement of any specific instruments, tests, or procedures.”

So why did the Emory team decide to take this more conservative approach to lab testing? To their credit, the authors also address this issue head-on:

"The degree of containment afforded by this facility substantially exceeds CDC guidelines for managing Ebola, a nonairborne pathogen that is transmitted principally via bodily fluids or direct contact and is readily inactivated by conventional disinfectants. The risk and routes of contagion with Ebola are judged to be comparable to.….pathogens that are handled safely and routinely in conventionally equipped hospitals and clinical laboratories using universal, contact, and droplet precautions. Given the availability of this specialized quarantine facility at our institution, however, it was deemed appropriate to use it in caring for these patients in order to afford maximal safety and reassurance to our hospital staff and patients, to avoid disrupting other hospital operations, and to respect the heightened public and media attention prevailing at the time, as these were the first cases of Ebola infection to be treated in North America"

To paraphrase: (1) we have an awesome quarantine facility so we’re damn well going to use it, and (2) everybody is freaking out, so we need to respect that.

My paraphrase sounds snarky, but I'd argue that their response was completely understandable and I can’t say I wouldn’t have done the same if I were in their shoes (or leg covers, or Tyvek suits). The problem is that generalizing from the Emory experience is not realistic for other hospitals, and could be dangerous for patients presenting with “severe non-Ebola infection” who happen to have been in an outbreak area in the prior 21 days.

Fecal transplantation: Not just for medical journals anymore

A new piece in the Atlantic by science writer Amanda Schaffer is the best article in the mainstream media on fecal transplantation that I have seen (and I think I've seen them all). She tackles a complex topic, makes it understandable without losing the nuance, and covers both the medical and regulatory aspects.

Reading the Post-apocalypse

Post-apocalyptic fiction is all the rage these days. Before the Divergent series, The Hunger Games and The Road by Cormac McCarthy and even before Orwell's 1984, there was The Scarlet Plague (1912). Michele Augusto Riva and colleagues have just published a wonderful review of post-apocalyptic (post-plague) fiction in the October EID. Specifically, the authors focus on the literary history of pandemic infectious diseases from the Bible and Thucydides' History of the Peloponnesian War to Mary Shelley's Last Man (1826) and Jack London's The Scarlet Plague.

The Scarlet Plague takes place in 2073 after a 2013 "Red Death" pandemic that depopulated the earth in 2013. The novel tells "how the pandemic spread in the world and about the reactions of the people to contagion and death." Initially, people were convinced that scientists would be able to treat the bacteria (public trust in science was apparently high in London's version of 2013) but quickly the bacteria spread killing all within hours. Both London's novel and Riva's review are worth reading. There are many insights to be gained by looking at past responses to outbreaks (2009 H1N1, SARS) and fictional responses, as in London's novel, as we face current and future threats like Ebola, MERS and avian influenza.

Love The Glove

It's pretty easy to hate on gloves. They're certainly annoying to put on and wear. Yet, much of what we do in medicine is difficult yet worth it, if what we do is effective. Now if we really could get hand hygiene compliance beyond 90%, I think a narrow focus on hand rub utilization would be OK. But, irrespective of what facilities are reporting, when you really look, their compliance is closer to 50% (if they're lucky). That's why I continue to (a) encourage investment in hand hygiene research and (b) recommend glove use in our infection control bundles.

In a recent JAMA Pediatrics, David Kauffman and colleagues reported the results of a single-center RCT comparing mandatory glove use before all patient and IV catheter contacts vs hand hygiene alone. The study took place in the NICU during 2008-2011 and was funded by University of Virginia and Cardinal Health Foundation. The 120 enrolled infants (60 in each arm) needed to weigh less than 1000 g and/or have a gestational age less than 29 weeks and age less than 8 days old. The primary outcomes were infection in the bloodstream, urinary tract, or cerebrospinal fluid or necrotizing enterocolitis.  Randomization was fairly effective; however, the glove use arm neonates were more likely to have a central line, require mechanical ventilation and receive TPN.

Their were several significant difference between the outcomes in the two groups. Neonates in the glove-use arm had lower rates of late-onset invasive infection or necrotizing enterocolitis (32% vs 45%, p=0.13), fewer Gram-positive BSIs (15% vs 32%, p=0.03) and fewer CLABSI (3.4 vs 9.4/1000 catheter days, p=0.01).  Frankly, with such a small study, I'm surprised they found any significant differences. What would I recommend after reading this study? I would recommend (a) NIH/AHRQ/PCORI fund a follow-up multicenter study to validate these findings and (b) in the meantime, wear gloves when caring for pediatric patients based on this study and our earlier study in Pediatrics.

Ebola perspectives from a BSL-4 virologist

Our colleague Tara Smith just posted an interview with Dr. Heather Lander, a virologist who works with hemorrhagic fever viruses. From this interesting interview I linked to her new blog, “Pathogen Perspectives”. She addresses some of the Ebola transmission issues we’ve touched upon, and more. Check it out!