The resistance continues...and you can help!

Billions & Billions (Eric Daigh) Each of the 34,800 pills in the picture represents 1 million doses of antibiotics, totalling 34.8 billion doses given each year around the world. 

 

 

As SHEA president this year,  I have not been doing much blogging but I have been traveling and learning and representing SHEA in many different places.  In the last few weeks, I was able to attend the International Conference for Prevention and Infection Control (ICPIC) in Geneva and also attend a ‘side event’ at the United Nations General Assembly focused on antimicrobial resistance. 

In Geneva, I heard about efforts to combat and contain multi-drug resistant infections in many different countries.  (I also realized that many European countries are still struggling to raise their healthcare worker influenza vaccination rates over 40 or 50%!)  In addition, Kristy Weinshel, SHEA executive director, and I met with leaders from WHO to discuss how SHEA can best support WHO efforts to improve infection prevention and antimicrobial usage around the world.  We discussed training courses to develop local expertise in resource limited countries, continued engagement of past participants in SHEA’s International Ambassador program, and adaptation of infection prevention guidance for these challenging settings.

In New York city, at an event sponsored by CDC, ASM, the Gates Foundation and Wellcome Trust, we heard from DHHS Secretary Azar, a young man who survived a multi-drug resistant infection after a train accident in India, “England’s CMO” Dame Sally Davies and others about the risks of continued antimicrobial overuse in agriculture and in medicine.  The night also included multi-media artworks including comic books about a post-antibiotic apocalyptic future, ‘petri dish’ microbial art including a street map of NYC and Van Gogh’s sunflowers, textiles stained with bacterial growth and the picture above  Many countries, individuals, companies and organizations were there to celebrate progress since last year’s commitment in The AMR Challenge and to re-commit to continued progress. 

One of SHEA’s commitments is to expand scholarships in order to continue to grow the community of experts that can improve the appropriate use of antimicrobials in human populations.  These scholarships are used to support education for physicians, pharmacists and other providers who are involved in stewardship research or practice.  Since 2015, SHEA members have raised over $30,000 through our annual Race AgainstResistance, originally conceived by Judy Guzman-Cottrill and carried forward by David Calfee.  Due in part to support from all of you, last year I was the leading fundraiser, without running a step!  This year my speed reading team of 1 (me!) is in 4^th place behind some stiff competition from actual athletes.

Now’s your chance to help!  Donate to the Race Against Resistance (pick any team)! Help fight the spread of antimicrobial resistance!  Help SHEA fund colleagues building skills in antimicrobial stewardship research and clinical practice!  Help prove that you don’t have to be an athlete to raise money (look for the team picture that is a book and a cocktail)!

Hope to see many of you at IDWeek next week! 

Time to Review Your Hospital Tuberculosis Control Plan: Updated CDC Guidance

This is a guest post by Jorge Salinas, MD, Hospital Epidemiologist at University of Iowa Hospitals and Clinics.

The National Tuberculosis Controller Association (NTCA) and the Centers for Disease Control and Prevention (CDC) just published their updated guidance for the prevention of M. tuberculosis (TB) transmission in healthcare settings.

The previous guidelines (2005) called for tuberculosis screening for all healthcare workers upon hire and yearly if working in medium-risk settings. The setting risk was calculated based on the number of TB cases seen in the previous year. While most United States Hospitals were considered low risk, many large academic medical centers and hospitals in states with a higher incidence of TB were considered medium-risk. Fortunately, a number of studies performed in developed settings show that the rate of latent TB infection among healthcare workers is not different than the general population. In the updated guidance, hospitals previously considered medium-risk would continue testing upon hire but discontinue yearly TB screening (tuberculin skin testing or interferon gamma-release essay). This recommendation is welcomed as employee health resources can then be allocated to other emerging concerns (e.g., maximizing immunizations among healthcare workers).

The new guidance does not reduce the requirement for fit testing likely because the current TB infection prevention measures (administrative and environmental controls and personal protective equipment use) are likely the reason for such low levels of TB transmission among healthcare workers. As more data is gathered, next research steps could involve studying the necessary frequency of fit testing or the best method used (qualitative or quantitative methods).

These new recommendations will need to be accompanied by adequate contact investigations in healthcare settings. In the past, even if some contacts were not identified, the routine yearly screening would detect those patients within one year of the exposure. Now, an unidentified contact could go unnoticed until TB disease occurs. This increases the importance of training and knowledge of TB contact investigations in healthcare settings. However, TB contact investigations in healthcare settings are not straightforward: healthcare workers may have baseline positive skin testing and it is difficult to quantify the exposure risk (there is no standard recommended threshold for distance from patient or duration of exposure). Even if there was a recommended threshold, it would likely vary depending on other factors such as patient infectiousness (cavities, smear positivity) and healthcare worker immune status. Out of caution, healthcare workers may also tend to overreport exposures potentially overwhelming infection prevention programs. Another unique aspect of TB in healthcare settings involves extrapulmonary TB. Although in public health settings extrapulmonary TB is deemed likely not transmissible, it may lead to exposures in healthcare settings, especially during wound care, or procedures that may generate aerosols or splashes (irrigation, or bone surgery).

Congratulations and thank you to NTCA and CDC for their updated recommendations in light of new evidence. Those on the frontlines (Employee Health and Infection Prevention programs) will be able to reallocate resources and put their TB contact investigations skills to test.

SENTRY at 20: So many bugs!

The SENTRY Antimicrobial Surveillance Program was begun at the University of Iowa in 1997, moving a few years later to JMI Laboratories (also in Iowa!). Since inception, it’s been an industry-funded platform that performs central laboratory testing of clinical isolates of bacteria and fungi from centers around the world. The isolate submission process has been consistent over time, involving submission of organisms from consecutive episodes of infection at specified body sites (more information here and in the many publications that have come from SENTRY). 

So SENTRY has been operating for >20 years, and there are hundreds of thousands of isolates characterized. The major trends are reported in an OFID supplement and in recent publications in JAC and AAC. The supplement articles and the AAC report on trends in 20 years of bloodstream infection (BSI) isolates are open access—take a look if interested! 

I’ll focus briefly just on the AAC report (which I first-authored, so that’s shameless self-promotion right there)—two major points, each of which confirms on a large scale what regional surveillance programs have reported:

• S. aureus and E. coli dominate the BSI landscape—together account for >40% of all episodes reported to SENTRY. Continued focus on prevention, detection and treatment of these two bad actors is critical, and IMO should include vaccine approaches, despite the disappointments to date.
• There’s an interesting divergence in proportion of BSI caused by important resistance phenotypes among Gram-positives (MRSA, VRE, DRE, etc.) versus Gram-negatives (ESBL, CRE) over the second decade of surveillance (2005-2016). The Gram-positive resistance phenotypes are stable-to-declining, whereas Gram-negative phenotypes steadily increase (as proportion of BSI episodes) over the entire surveillance period.

The decline in MRSA as a proportion of all SA BSI is particularly striking, occurring as it does at the same time worldwide (and at all body sites, both healthcare- and community-onset, as more detail in the OFID report of all SENTRY S. aureus confirms). As Eli and I discussed in this JAMA editorial almost 10 years ago*, this is not easily explained by hospital-based infection control interventions. The waxing and waning of epidemic clones of MRSA is more likely to be informative. There is so much we still don’t understand about an organism (S. aureus) that lives in relative harmony with 20-30% of the human population when it isn’t causing horrendous, difficult-to-treat infections.

Finally, the scope and number of isolates collected by SENTRY and similar programs represent an underutilized public health resource. Regulatory requirements for drug development and approval mandate surveillance for AMR. Better partnerships between public health authorities and the industry sponsors of such surveillance programs could enhance surveillance and response, particularly in the genomic era when ready access to large isolate collections can be so powerful. Some of this is already happening, but more could be done.

*still behind a paywall after 10 years?  What gives?

HAI Controversies at 10 years

It’s been a decade since we started this infection prevention blog. So I was planning to write a reflective post on whether it was still relevant, why I'm blogging less frequently, perhaps expand upon Eli’s post about why he stopped blogging, and maybe even add my voice to all those proclaiming that “blogs are dead”. 

So I went to our blogger stats page to get some data, and found a few interesting tidbits: this blog has had over 3 million page views since its inception, and is still getting over 10,000 page views monthly! Is this accurate? I have no idea, but it persuades me to hold off, at least for a while, on predicting the demise of the blog. 

A few other fun observations from the stats page: see the huge spike of page views in late 2013? That resulted from an almost 2-year old post being picked up in a Reddit thread (a post by Mike about neckties). The next four most-viewed posts in the blog’s history are about toilet lids for infection prevention, contact lenses, sinks and Fusarium, the inability to eradicate M. chimaera from heater-cooler devices, and the epic Skullcap Feud still raging between surgeons and AORN. With topics like these, who needs cat videos?

We started the blog to have a forum for freewheeling, even hyperbolic, discussions of controversial infection prevention topics. I think much of that back-and-forth has moved to Twitter. I’ve now come to believe that the blog is at its best during the early stages of outbreaks/crises that impact hospital infection prevention programs—to provide updates, opinions, suggestions for colleagues struggling with the same issues. The best recent example is the global M. chimaera outbreak, posting our thoughts as we navigated our own hospital response. For these complex situations--especially in the early, evidence-free phase--a blog post may allow for more nuanced discussions of the pros or cons of different approaches. Though I've been pretty impressed with some of the amazing twitter threads I find on med Twitter, a great example being this discussion of the Merino Trial.

I guess we should definitely have a larger discussion about the relevance of medical blogging.  Maybe on Twitter....

Yes we can!

In early 2009, I bought three North Face black vests for myself and my colleagues Gonzalo Bearman and Mike Stevens at VCU Medical Center. Our Infection Control Committee had recently recommended that all healthcare workers adopt a bare below the elbows approach when providing care in the inpatient setting. The vests were good at providing some additional warmth on winter days. We avoided fleece and opted for vests that were nylon on the external surface so that they could be easily cleaned with a disinfectant wipe. We started bare below the elbows with just three people in a hospital with a workforce of 10,000.

We didn’t mandate bare below the elbows and we didn’t aggressively push it. We rolled out an educational campaign with a personal infection prevention bundle that had three components: bare below the elbows, hand hygiene before and after patient contact, and stethoscope wipe down after every patient exam. We talked about it in new employee and new housestaff orientation sessions, always noting that this was a recommendation. We had no support from hospital administration, though no one tried to obstruct us. Importantly, we gave doctors permission to not wear white coats and neckties, and continued to role model the approach as we saw patients. Given how attached some physicians are to their white coats, we knew that a mandate would produce a backlash and doom our plans. Still we got some pushback, but our response to the naysayers was consistent, “You’re not required to do this. It’s just a recommendation.” It's hard for anyone to argue with that.

Here we are a decade later, and this week saw the publication of our results with this experiment in the American Journal of Infection Control. Across 40,000 observed encounters in calendar year 2017, overall compliance with bare below the elbows was 84%. Probably not too surprising, physicians were the laggards at 67%, with most other groups in the high 80s or even 90s. But having two-thirds of doctor-patient encounters occur without the 20-square-foot microbiological zoo (AKA white coat), is pretty damn astounding.

What’s also interesting is that in the prior year, overall compliance was only 40%. In hindsight, we can see that 2016 appears to have been the tipping point as compliance doubled in the ensuing year. Now, bare below the elbows is part of the institutional culture. I have given many talks in the past decade on this topic where I’ve been told repeatedly that doctors will never give up their white coats, but Gonzalo tells me that it is now unusual to see a doctor in a white coat on the wards.

There are a couple of lessons here. We’ve again confirmed that changing behavior in health-related interventions is a slow process (probably even slower when the person whose health is impacted isn’t the person whose behavior must be changed). But more importantly, you don’t have to beat people over the head to make it happen. Provide encouraging messaging, role model the behavior, and let uptake diffuse. Patience is key.

Kudos to Gonzalo and Mike for persisting, and to everyone at VCU in the 84% who stepped forward. When I start service tomorrow it will be 10°F here in Iowa, and though this poikilotherm would like to be bundled in 20 layers, you can bet your bottom dollar that I’ll be bare below the elbows.

A Blogger's Return: Relishing the Wave of Infection Prevention Science

Apologies, Faithful Readers (who do I think I am, Stan Lee (R.I.P.)?).  The day-to-day life of a hospital epidemiologist, IDWeek planner, dad and spouse have pulled me away from contributions to the blog.  But, like a bad rash, I'm back!  I was prompted to post not because of a single study or bit of news but because of a thought I had when I received the TOC for the latest issue of Infection Control and Hospital Epidemiology (Disclaimer:  I am a member of the editorial board but did not review any of the articles in this issue including those noted below).  I was struck once again at the diversity of topics and the increasingly strong science that's being performed in our field.   Makes me happy to be a hospital epidemiologist for sure!  A few highlights:

• A systematic review/meta-analysis examining whether evidence supports use of cefazolin for surgical prophylaxis in hysterectomy.  The authors noted a significantly higher SSI risk with cefazolin vs. cefoxitin or cefotetan (risk ratio, 1.7; 95% CI, 1.04–2.77; p = 0.03) and highlighted numerous limitations with the existing clinical studies.
• A human factors analysis of PPE doffing that identified 103 failure modes with PPE removal (including issues related to the person, the place, the equipment, and the training).
• An analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data to examine if placement in isolation adversely affected the patient experience (while isolation patients noted worse experience in the general ranking of overall care and in aspects of staff responsiveness, experience was similar in all other domains).
• A thoughtful commentary on defining antimicrobial never events that include inappropriate surgical prophylaxis, use of antibiotics for viral URI, and use of antibiotics for asymptomatic bacteriuria (as my hospital uses a Patient Harm Index of raw events for our quality goals, I love this concept, as it gives antibiotic stewardship some clear measures that fall into that framework).
• Another nice analysis illustrating that claims-based billing code data are not useful to assess infection rates (this time: SSI) when compared to NHSN surveillance gold standard.  Use to rank hospital quality is even stickier, as illustrated by the finding that 65% of hospitals in the best quartile by claims data were ranked in worse quartiles by NHSN data.

And there are so many more excellent studies and manuscripts, so check it out (and keep pushing the IP evidence base forward)!

The landscape of MRSA in America's largest healthcare system: Acquisition carries a 1-4% chance of infection in the following year!

Note to readers: This is another guest post by esteemed FOTB (friend of the blog) Dr. Daniel Morgan. Soon I'll give him the keys, in the hopes he'll post more frequently!

One of the most informative articles I’ve read in 2018 on healthcare-epidemiology has largely sailed under the radar. This article summarizes the numbers for MRSA across the US Department of Veterans Affairs (VA). In the VA we perform active surveillance testing on admission and discharge to acute and long term care centers. A wealth of data is collected reflecting community and academic settings across all regions of the country. The reporting of extensive numbers without a single message probably made this study less eye-grabbing. The excellent team of data-savvy researchers at the Salt Lake City VA/University of Utah have done extensive cleaning and validating to come up with outcomes for almost 1 million first admissions from 2008-2015. Yes, 1 million patients who had MRSA surveillance tests on admission and discharge. They then followed them for a year post discharge to look for infection. Some may quibble that “acquisition” isn’t using whole genome sequencing but no past study comes close to having this much data. Congrats to Rich Nelson, Mike Rubin and colleagues! People should be dissecting these numbers for much guidance on MRSA. (And Mike, sorry to Lance Peterson you by reinterpreting your own data…but at least I didn’t title this “Mike Rubin’s team shows MRSA surveillance and isolation are of low value!”) 

A few nuts and bolts:

I will focus on non-ICU admissions for ease of numbers, but ICU conclusions are almost identical. There were 902,354 total patients admitted to non-intensive care units. 

• 7.3% (65,783 patients) were MRSA + on admission 
• Fewer than 1% (0.81%, 7,342 patients) acquired MRSA (negative on admission, positive on discharge)

They defined infection a few different ways: 

• Definite infection: MRSA + culture from sterile site—blood, CSF etc. 
• Likely infection: All Definite infections & patients on anti-MRSA antibiotics within 5 days culture 
• Possible infection: Any positive MRSA culture from any site (reflecting colonization and infection) 

Some conclusions: 

Acquisition of MRSA carries a small risk of developing infection. In contrast to past articles, across a broad population, this is true even within a year of admission. For non-ICU admissions, acquisition of MRSA carried a 1%-4% risk of definite or likely infections within a year. (7% risk of possible infection) (even if discharged from an ICU the numbers are only 2.5-8.6% develop infections or colonization) 

Previous studies have reported an absolute risk > 30%! Studies were often in a single tertiary care center, displaying how little those hospitals reflect the general population. This means THE BENEFITS OF PREVENTING ACQUISITION OF MRSA ARE SMALL. (Infections, however are important) 

I know Eli and other friends may disagree, but we need to focus on infections. Preventing those is the metric that matters. >95% of patients wouldn’t even know they acquired MRSA (as they never would have had an infection). 

The vast majority of MRSA infections occur in people who were MRSA + at admission, not those who acquire MRSA. This paper estimates that fewer than 10% of definite or likely MRSA infections occur in those who acquire MRSA during the admission. Let’s focus our efforts to prevent most MRSA infections. Contact precautions don’t help people who are already colonized. They instead require infection prevention efforts like device insertion bundles, chlorhexidine, and avoiding antibiotics. 

The official conclusion of their paper--that acquiring MRSA poses greater risk than being colonized on admission--is true, but the effect is small: ~1% absolute difference. 

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Bad news for all haters of Staphylococcus aureus disease. Pfizer just announced their large Phase 2b clinical trial for a S. aureus vaccine to prevent post-operative infections with S. aureus among spinal surgery patients was futile to continue. 

press release

Exactly what this means for the Pfizer staph vaccine program is unclear. according to the press release, there was no indication of any safety concerns, but rather a low likelihood of the study to reach statistical significance of any of their primary clinical endpoints: 

• S aureus BSI and/or deep incisional or organ/space SSI occurring within 90 days of elective open posterior spinal fusion procedures with multilevel instrumentation. 

STRIVE was evaluating a Staphylococcus aureus 4-Antigen (SA4Ag) Vaccine. I have to admit I did provide some consultation to Pfizer's advisory group on this study, including a modest one time consulting fee (full disclosure!); however I have no insider information on the trial itself. As an advocate for making the public health case for a S. aureus vaccine, I (again) find this development extremely disappointing.  

We hear reports that MRSA incidence is improving, mostly from NHSN type reporting - but to be honest I can't really find contemporary data to tell a clear story about S. aureus incidence in past few years. I know we are all making good progress with HAI prevention, hospital-onset MRSA, probably even S. aureus HAIs in general - is there room for clinical trial work in this arena?! or is S. aureus just a problematic pathogen to develop a vaccine!  Well a big thank you to Pfizer and NIH and the other Pharma companies rising and investing to develop an efficient S. aureus vaccine - I am sorry STRIVE has ended, I hope the healthcare epidemiology community can continue to produce data to help make a rational argument for companies to invest in such development!.  

happy new year!

Scott.