Mycobacterium chimaera: How big is the iceberg? And about that iceberg...

The reports of invasive M. chimaera infections linked to heater-cooler devices keep rolling in, but still nobody has any idea how big this problem is. Mike and I each get sporadic e-mails or calls from places where new cases have popped up, and I’m convinced we are still dealing with the proverbial “tip of the iceberg.” The knowledge that invasive M. chimaera disease should be in the differential for certain symptoms after cardiac surgery is still spotty, and confined to those who practice ID or cardiothoracic surgery. Most patients who develop vague symptoms like weight loss and fatigue (even those who got a valve replaced a year ago) are likely to go to their primary care physician first. Only those affected who encounter someone familiar with this global outbreak are likely to get the right diagnostic evaluation (to include AFB cultures). Hence this pattern: a case is detected in a given location, after which there is a lot of attention focused on the problem, including media reports and provider notifications, and then several more cases are discovered.

My current unofficial (and extremely incomplete) global case count is at least 108, which includes cases reported in the news or in published reports from public health agencies, meetings, or journals. This count includes cases from US (New York, Ohio, Pennsylvania, Michigan, Minnesota, Iowa, Tennessee, Florida, and California), England, Ireland, Switzerland, Germany, Netherlands, France, Spain, Hong Kong, and Australia.

I’m sure there are many more we’ve not heard about, so feel free to email or comment below if you know of others. The bottom line is that we are long overdue for (1) mandatory public reporting of invasive non-tuberculous mycobacterial disease, and (2) a global registry to track this outbreak, and to help inform diagnosis, treatment and prevention approaches.

Now about that iceberg…I’ll bet the iceberg above is the most common single image used in presentations about infection prevention and antibiotic resistance (possibly several other fields, too). It’s a great graphic for depicting the idea that a problem is much bigger than it may appear on superficial or initial assessment (for example, that clinical cultures miss the vast majority of carriers of resistant organisms, or that active TB cases are vastly outnumbered by latent TB cases). I think I’ve used that graphic in at least 2 dozen talks, maybe more. When I saw it again last week, I started to wonder from whence it came. To my mild disappointment, I found that it isn’t a real photo (it’s too good to be a real photo!), but is actually a composite of four different photos. For more information, see here—the credit for the digital composite goes to Ralph A. Clevenger, according to this account.

Anyway, as a profession I think we should move on to a different iceberg photograph. I nominate the one below, by Joshua Holko, based upon the facts that (1) it is an actual photo (I hope!), (2) it still shows how large the portion of the iceberg below the water is, and (most importantly), (3) it has penguins!

Join The Race Against Resistance

This is a guest post from Judy Guzman-Cottrill. Dr. Guzman-Cottrill is a Professor of Pediatrics at Oregon Health & Science University and also an infection prevention and healthcare epidemiology consultant for the Oregon Health Authority’s HAI Program, where she serves as the Medical Director for Ebola and Emerging Pathogen Preparedness. 

Last week Judy and I attended a SHEA Foundation Board Meeting where, during strategic planning discussions, this important fundraising event was discussed. I hope you can run, ride or contribute! - EP

It’s time to dust off those running shoes and road bikes! Last year, the SHEA Education & Research Foundation (ERF) organized its first Race Against Resistance Fundraiser, and it was a great success. Runners raised over $23,500 for new SHEA ERF Scholarships, and these scholarships are currently open for applications, with a May 5th deadline.

Given the great success in establishing these new scholarships, we are now planning the 2017 Race Against Resistance! We would like to expand the volunteers to both runners and cyclists. Participants choose a local non-charity race between SHEA Spring 2017 and IDWeek 2017.  Funds raised will continue to support SHEA ERF-sponsored education opportunities in the field of antibiotic stewardship. The top fundraisers (and affiliated hospital) will be recognized at the SHEA Business Meeting as a part of IDWeek 2017. The race must be pre-approved by SHEA organizers, and all participants must finalize their race selection by March 30, 2017 to be listed on a competition webpage for fundraising purposes. Please contact Kristy Weinshel at kweinshel@shea-online.org to become a 2017 fundraiser, or if you’d like more details.

Are you wondering who raised the $23,500 last year? Here are last year’s racers and how much they were able to fundraise for SHEA ERF scholarships!

Putting contact precautions in their place

Last September, I had the honor to attend the Infection Prevention Society's Infection Prevention 2016 conference in Harrogate, England. During the conference, I was fortunate to meet Professor Graham Ayliffe and give the annual Ayliffe Lecture on the Science Behind Hand Hygiene and I also got to meet and discuss infection control with many of the dedicated members of the Society. Attending the IPS conference was a great way to learn how infection control interventions are implemented in other countries.

In particular, I greatly enjoyed meeting and debating! Dr. Fidelma Fitzpatrick of The Royal College of Surgeons in Ireland and Beaumont Hospital in Dublin. I was charged with debating For contact precautions and Fidelma was charged with Against. At the end of the debate, we realized that there was much common ground in our understanding of where and when to implement contact precautions for MDRO prevention. In particular, we realized that the underlying context in which contact precautions are implemented, de-implemented or studied is critical. And by context, we mean things like availability of single rooms or the baseline (poor) hand hygiene compliance in your hospital. With that in mind, Fidelma and I just published what we learned in a JHI opinion piece called Putting contact precautions in their place. In addition to highlighting the very poor evidence supporting de-implemention of contact precautions, we concluded:

"Where we implement or de-implement CPs will depend on how we frame the literature findings and our local institutional infrastructure, epidemiology, specific MDRO rates, patient factors, and institutional culture along with the local staffing and laboratory capabilities."

Jon Otter at the Reflections blog had a nice overview of our debate. He concluded:

"It was a slightly odd set-up in that Fidelma was arguing against contact precautions from a hospital that uses them, and Eli was arguing for contact precautions from a hospital that doesn’t! But I got a sense that the debaters were putting across genuine views, and not talking to a side of the debate they didn’t subscribe to. My conclusion: contact precautions make sense and fulfil the logical idea of ‘disease segregation’. The studies that seem to show stopping them makes no difference are probably explained to a large degree by the fact that they’re not done right in the first place! It was interesting that all agreed that you should apply contact precautions for the ‘really bad bugs’ (like CPE and C. difficile diarrhoea), so what is the logical difference between these and other organisms?"

Post debate, the attendees were charged with voting Against or For the motion supporting contact precautions with their feet. A fun idea!

Wherein I reveal the top 3 approaches for preventing C. difficile disease!

1. Antibiotic stewardship

2. Antibiotic stewardship

3. Antibiotic stewardship

I’ve listed these in order of importance. Supporting evidence is accumulating, including three recent papers that I found very interesting:

Dingle, et al. Lancet Infect Dis 2017. This observational study from Oxfordshire, UK combined overall CDI rates, antibiotic use data, and whole genome sequencing to determine whether declining CDI rates were more likely driven by reduced antibiotic use or by transmission prevention efforts. The results are nicely summarized in Figure 2 from their manuscript (see below). It’s extremely cool to see how the big reduction in fluoroquinolone (FQ) use from 2005-2007 was followed by the near-extinction of FQ-resistant isolates. The disappearance of these FQ-R genotypes accounted for the entirety of the significant CDI reduction seen in Oxfordshire. If infection prevention approaches were a major driver of the CDI reduction, one would’ve expected to see at least some reduction in the non-FQ-R genotypes. Equally interesting: as FQ use crept up, rates of FQ-R CDI didn't follow, possibly due to eradication of these genotypes from asymptomatically colonized, or due to the still-lower usage (or usage in different populations). Anyway, there’s a lot of great detail in this report, so read it yourself, but the results support the centrality of stewardship to CDI prevention. LATE ADDENDUM: See this post by Marc Bonten and this Wellcome Open Research article for important caveats to the above "simple interpretation" of this study.

Anderson, et al. Lancet 2017. I’m kind of embarrassed that we haven’t weighed in on this one yet, since the Benefits of Enhanced Terminal Room (BETR) Disinfection study is definitely “BETR” than most infection prevention studies. It’s a cluster-randomized, multicenter, crossover study that compares standard disinfection to bleach, UV-C, and bleach + UV-C for terminal room disinfection after occupancy by patients with MRSA, VRE, multiple-drug resistant Acinetobacter, or CDI. The outcome is acquisition of colonization or infection with the index organism by the subsequent room occupant. One reason I haven’t blogged about the study yet is that I really don’t know what to make of it. It’s a great study, but some of the results are confusing or counterintuitive, and don't make me want to rush out and buy more UV robots (full disclosure: we have a whole army of them at our hospital already, all of which were purchased prior to the results of this study). For rational takes on the entirety of the study I’ll outsource to our colleagues Jon Otter and Marc Bonten at Reflections IPC. As for the C. difficile results (see below for per-protocol results from Table 3 of the manuscript), UV-C didn’t reduce CDI risk beyond that of standard bleach disinfection. For the purposes of this blog post, I’m going to concur with the authors’ contention that “the environment might not play as large a role in C. difficile transmission as previously suspected” (or at least not as large a role when you’ve already cleaned said environment with bleach). It’s all about the antibiotic stewardship, baby!

Widmer, et al. Clin Infect Dis 2017. This is the laziest, least resource-intensive of these three studies, and also my favorite. What better way to determine whether an intervention to prevent transmission is effective than to just stop doing it and see what happens? [I’m now picturing Andreas Widmer leaning back on his office chair, feet on his desk, overseeing a decade of not placing CDI patients in contact isolation.]  I’m kidding, of course, in fact they did quite a lot of sampling of the contacts of these CDI patients (451 of them) to assess for transmission events. The upshot: only 2 (!) proven (and 4 probable) transmission events were documented using genome sequencing over the decade, and no outbreaks occurred. Of note, they did place those with “severe incontinence” in contact isolation (really, this is in the spirit of Standard Precautions), and all CDI patients were assigned a dedicated toilet. Oh, and they also had no active antibiotic stewardship during this time period, but report a >90% adherence to hand hygiene (paging Eli!). 

To sum up: three interesting studies, and the combined results lead me to conclude that, assuming I have a limited budget with which to reduce CDI, I’d be wise to invest most of it in active antibiotic stewardship.

Fake News in Your Hospital: Hand Hygiene Compliance

Fake news and how it influences policy and politics has been grabbing headlines lately. I'm sure many who read this blog are rightly concerned about this development. If we can't even agree on the truth, how can we set about making policy and solving problems?  What struck me about the fake news discussions is that we have an example of fake news in our hospitals - reported hand hygiene compliance!

A few weeks ago, I wrote that hand compliance in your hospital is likely between 34% and 57%, since a review of trials published since 2009 reported those levels before and after interventions were implemented. Apart from that study, how can I know your true compliance rates when you're reporting hand hygiene compliance rates over 90%?  I have several reasons.

First, harken back to this 2010 interview of Mark Chassin, then and current President and CEO of The Joint Commission. In the interview, he shared the initial results of their "proven effective solutions for improving hand hygiene compliance in hospitals", which were developed in 8 center hospitals and further evaluated in 29 additional hospitals.  At the beginning of this project, hand hygiene compliance was 48%. Look at what Dr. Chassin said about the baseline rate - "It’s interesting that a number of the hospitals were misled by faulty data to believe that they were doing as well as, say, 85%, at baseline rather than 48%."

Second, even after their huge hand hygiene initiative, they were only able to get compliance up to 82%. Interesting, so even The JC acknowledges that you can't get to 90% compliance. Yes, but that was 2010, what about 2017?

Third, The Joint Commission's National Patient Safety Goal 07.01.01 for 2017 doesn't require hand hygiene compliance over a specific threshold (see Figure below). Hospitals only have to set goals for improving compliance and then improve compliance based on those goals.  So why do hospitals continue to set unreachable goals for hand hygiene compliance (say over 90%)? Are there downsides with setting fake goals - do they hurt our credibility, do they result in a feeling of learned helplessness among clinical and infection prevention staff and do they harm our patients?

____________

Side note: One of the things that struck me when rereading the Chassin interview is the dissonance between the primary barrier to hand hygiene compliance that The Joint Commission identified and their planned "next steps" to get compliance above 82%. I pasted the quotes below. Do you think their interventions addressed the identified barrier?  Me neither.

Primary Barrier: "So, for example, for one of the causes (“hands full”), which was a surprise for many of the participants, caregivers approach a patient’s room with their hands full—for example, a nurse is carrying materials to do a dressing change—and there’s no place to put the materials down. The hand-gel dispenser is right there, on the wall, but there’s no place to put the materials down, so what do you do?"

Joint Commission Solution: "We’re looking to industry to address one of the more difficult parts of sustaining and getting past 80%, namely, replacing this very labor-intensive measurement system with devices, software solutions, and applications that are relatively inexpensive but will provide real-time feedback on performance."

Image Source: AIM