Prevention in Portland

Last week, several of your friendly neighborhood bloggers (Hilary, Scott, Mike, and yours truly) were among the attendees at this year's SHEA Spring Meeting, held in Portland, OR, and it was great to see how this iteration of the meeting has matured in just a few years.  The Planning Committee, headed by Matt Linam and Judy Guzman-Cottrill (who also hooked us up with some awesome Gram-positive and Gram-negative tailor-made SHEA Voodoo Donuts), did an outstanding job weaving the three traditional training courses (Healthcare Epi, Antibiotic Stewardship, and IP in Post-Acute and Long-Term Care -- check them out next year if you've never attended!) with many general meeting sessions that included important updates, pro-con debates, and impressive science.  The theme of the general track focused on communication, and the plenary sessions included pragmatic discussions of messaging to diverse stakeholders, to the media (with NPR's Joe Palca), and to government stakeholders through advocacy. 

I'm still unpacking everything I enjoyed about the meeting, but to highlight a few things:

• The meeting size was just right to network with old colleagues well as the growing number of new faces in the field
• The posters were held in a converted parking garage, which felt very old school SHEA ("We don't need no fancy ballroom to learn science!")
• Antibiotic stewardship remains very hot, and it was great to see the innovation and engagement on this very important issue (and the continued presence of our pharmacy colleagues at this meeting).  Also nice to see the emergence of diagnostic stewardship at the meeting.  There were several posters on reducing unnecessary urine cultures and C. difficile testing, for example.
• Not to be outdone by stewardship, infection prevention topics hit on some key challenges, including how to influence and change behavior (including the first? ever pro-con where a vegetable was introduced as a dueling weapon), barriers and innovations to improving use of PPE and hand hygiene, and discussions about risk-adjustment of reported HAI data, the limitations of surveillance definitions, and the possibility or folly of "chasing zero."
• Seeing the finalists for the SHEA Epi Competition expertly field many tough questions about their proposed projects -- and congrats to Valerie Vaughn from Univ. of Michigan on winning the $20,000 award for her project entitled "Antibiotic Overuse at Hospital Discharge."
• Getting to watch Scott's son, Daniel, present  like a pro as probably the youngest SHEA presenter in history (on an impressive look at CRE and transfer networks in Atlanta)

There's so much more to hit on, I invite my co-bloggers to jump in! Suffice to say it was a very successful meeting and a very nice partner to our fall extravaganza, IDWeek (Oct 3-7, 2018 in San Fran - register now!).  Next year, it's in Boston (April 24-26, 2019), so block your schedules!  Perhaps Eli will host a 10th blogiversary celebration?

A Research Agenda for MDRO Prevention

Of course, I don't need to explain the clinical importance of multi-drug resistant bacterial pathogens to readers of this blog. I probably don't need to remind you that "more research is needed" either - that's why we have controversies! But, I should probably point you to five papers recently published in ICHE that outline the future research agenda for MDRO prevention in the US Veterans Health Administration (the VA).

For our non-US readers, the VHA is the largest integrated healthcare system in the United States with over 130 acute care facilities, 1000 outpatient clinics, numerous long-term care facilities and 9 million enrolled patients. The VA has been a leader in medical and health services research for decades and has been well-ahead of the curve in application of interventions to prevent MDRO including its MRSA prevention bundle and antibiotic stewardship initiative.

To continue the VA's success in MDRO prevention and link future research questions to the greatest clinical need, we invited a multidisciplinary group with 37 participants to Iowa City in September 2016. The aim of the panel was to outline the VHA's research agenda for MDRO prevention. Dan Livorsi describes the process we used to identify the domains and research questions in an introductory editorial. The outlined research agenda was broad in scope and included efficacy, effectiveness and implementation questions. In addition, many of these questions are broadly applicable to study in non-VA and non-US hospitals. We are all more alike than different.

Research questions fell into four domains:

1. Transmission dynamics: Resistant pathogens are spread via human hands and environmental surfaces. Disrupting this transmission is essential to controlling MDROs.

2. Antimicrobial stewardship: Strategies to reduce and improve the use of antimicrobials will slow the emergence of resistant pathogens.

3. Microbiome: There may be ways to manipulate or augment the human microbiome to eradicate or prevent colonization with resistant pathogens.

4. Special populations: Strategies need to be tailored to patient populations with distinct underlying conditions and in nontraditional care settings.

All 5 papers are open access. Thanks ICHE!  And thank you to the brilliant group of VA investigators, clinicians and operational partners who traveled to Iowa City and contributed to this effort. We all hope it's helpful.

Remember me if I forget (to blog)

#SHEA2018 has just started in Portland and since it's SHEA Spring, it's our blogiversary! Back in 2009, it all started with this post by Dan. We've been on quite a run - 1788 posts, numerous guest commentaries and a good share of controversy.

But you've probably noticed that we've been a little light on posts since around the end of 2016. This is for a variety of reasons, many of which you might guess - busy schedules, enrolling in degree programs, submitting grants etc. The biggest reason that I've rarely posted is that I deleted my twitter app. Since twitter is where I found many interesting ideas for posts, I've lacked some motivation.

But, 2018 is a new year - our 10th year  - and with new bloggers and light at the end of many tunnels, expect big things. I'll be off to Singapore for a good part of the year to learn about MDRO control there - I can imagine some "virtual postcards" from the Uncle Traveling Matt of the blog.

Finally, I saw the Tedeschi Trucks Band in Davenport last night. Amazing show. And Charlie Parr opened for them. Charlie is an amazing blues guitarist from Minnesota - he's a character in the coolest sense and told great stories. I can't get this song out of my head, so I thought I'd share it with you. Have a great time at SHEA - I can't be there. Please, remember me and remember our blog.

Great news from CDC! Help me to understand it...

Today our colleagues at the CDC’s Division of Healthcare Quality Promotion (DHQP) and the Tennessee and Iowa Departments of Public Health released an interesting MMWR Vital Signs report highlighting CDC’s efforts to control emerging antibiotic resistance (AR) phenotypes (main focus being carbapenem-resistance in Enterobacteriaceae (CRE) and Pseudomonas aeruginosa (CRPA)). The release is accompanied by a helpful summary of CDC’s efforts to better coordinate the detection and control of new and emerging resistance threats (including, of course, not only ESBL and CRE but Candida auris, colistin resistance, glycopeptide-resistance in S. aureus, etc.). Check it out!

My major takeaway: investments in laboratory detection of AR are beginning to pay off. By improving their diagnostic capabilities, more regional and state labs are now able to help health care facilities confirm, characterize and respond to pathogens that display unusual resistance phenotypes. This is unquestionably a good thing, though it still requires local facilities to be able to detect phenotypes of concern—for example, many hospitals don’t have ready access to MALDI-TOF or sequencing, and many do not identify Candida to species level routinely from non-sterile sources. How long might C. auris spread in such a facility prior to its detection? So although the AR Lab Network (ARLN) is a major step forward, we still need to emphasize that individual hospitals must invest in improved and timely AR diagnostics--and we ought to ensure they receive updated guidance about how best to detect new or emerging pathogens of concern.

Now for the data itself: the report presents NHSN CAUTI and CLABSI data from 2006-2015 on the percentage of all isolates of E. coli and K. pneumoniae with ESBL and CRE phenotypes over time. The ESBL phenotype was consistently detected in 16-19% of isolates over time, with no major change noted. However, the % CRE declined steadily, from a peak of 10.6% in 2007 down to 3.1% in 2015 (see Figure below). This is despite the fact that CLSI breakpoints for carbapenem susceptibility were lowered during the surveillance period, which should have caused more isolates to meet phenotypic criteria for resistance. And although the CDC published CRE-specific control guidance in 2009, the decline in %-resistant preceded this guidance (which would obviously not have been immediately implemented across the country, likely delaying any impact for 1-2 years). This also coincides with the spread of carbapenemase-producing Enterobacteriaceae (CPE) across the US. So I’m left wondering: why is the % CRE declining as a cause of CAUTI and CLABSI in acute care hospitals?

 

Is it related to the general improvements in infection prevention practices that have accompanied public reporting and pay-for-performance? Would such improvements differentially impact CRE over other pathogens (keep in mind this isn’t a rate, it’s a proportional decrease)? It’s clear that the epicenter of CRE/CPE seems not be in acute care but rather “post-acute care” as is also noted in the other part of the report (the results of CPE screening by ARLN labs for 9 months of 2017)….but I’d still expect increases in post-acute care or other health care settings to eventually be reflected in the NHSN CAUTI/CLABSI data. Granted, the NHSN data represents a relatively small number of organisms (for example, Clare Rock and colleagues demonstrated that CLABSI represent only 6% of all hospital-onset bacteremias).

I remain perplexed. And happy to hear any thoughts on this!