Controversies in Hospital Infection Prevention

Herd Immunity in the Jet Age

2012-01-27T14:20:00.000-05:00

By 2012, I thought we'd already be beyond the jet age. Although, if you go by the GOP debates, determining if a "moon-colony" could apply for U.S. statehood is now our top domestic concern, so maybe we're finally getting beyond the jet age?

An idea central to controlling infectious diseases is herd immunity. This is the idea that vaccinating a proportion of the population (e.g. 80% for mumps or 95% for measles) will protect the entire population, even the unvaccinated. In a paper presented recently at the meeting of the American Mathematical Society and the Mathematical Association of America and discussed in the Economist, Petra Klepac and colleagues wanted to know how increasingly mobile populations with varying vaccination rates would impact optimal vaccination targets for infectious diseases. That is, does it make economic sense to target a herd-immunity threshold? Also, how would high-levels of varicella vaccination in the US vs. low levels in Britain interact to impact chickenpox in both countries?

Dr. Klepac and her team used a susceptible-infected-removed (SIR) mathematical model, which we frequently use in analysis of infection-control interventions. Analysis of their model determined that targeting herd immunity makes sense for an isolated country. However, when international travel was added, she found that a small rate of unvaccinated travelers would reduce the optimal vaccination below the level of herd immunity, so that targeting herd immunity becomes too expensive. Thus, we have to be tolerant of more infections.

There are some other interesting implications of her study, so head on over to the Economist Babbage blog to read more.

Waiting for the Flu...

2012-01-26T23:03:00.003-05:00

"Shouldn’t we all be dead by now?" is the first question that Kent Sepkowitz, card-carrying hospital epidemiologist, asks in his latest article in Newsweek. He goes on to ponder why it's almost February and there's so little influenza activity and suggests that nothing we have done to prepare has made any difference including influenza vaccination and alcohol hand rub . He hints that perhaps La Nina or climate could be a possibility.

He concludes by saying: "In fact, what we are seeing here is the dark secret of medicine and public health: the fact that we usually have no clue why something, good or bad, is happening...(and) should accept that we are mere spectators to an inscrutable alliance of virus, animal, and climate, a longstanding collaboration that we cannot, as yet, influence — though getting that flu shot might help."

Kent Sepkowitz, Newsweek/Daily Beast 1/23/2012

Forget mandates, a song will bring them in!

2012-01-26T14:16:00.003-05:00

It never occurred to me to ask why people aren’t singing more songs about infection—but Slate’s William Weir is all over this, with an interesting piece that includes audio clips from songs about influenza, meningitis, plague and TB. For example, here are the lyrics from “Influenza”, recorded by Ace Johnson in 1939:

Influenza is a disease, makes you weak all in your knees
’Tis a fever everybody sure does dread
Puts a pain in every bone, a few days and you are gone
To a place in the ground called the grave

And definitely check out the clip from “Jesus is Coming Soon”, by Blind Willie Johnson. Play that at your staff meetings and just watch them all roll up their sleeves!

Photo: Blind Willie Johnson, public domain image from Wikipedia

New #OpenAccess Antimicrobial Resistance and Infection Control (ARIC) Journal Publishes First Papers

2012-01-26T12:36:00.002-05:00

Andreas Voss, Jan Kluytmans and Didier Pittet have successfully started a new international, open-access journal called Antimicrobial Resistance and Infection Control (ARIC). The first batch of papers were just posted today to the ARIC website. This event is a significant for several reasons.

The first, as I've mentioned before, is that as an open-access journal, ARIC will allow unaffiliated scientists, the general public and otherwise interested parties free full access immediately upon publication without having to wait years or pay high fees. In an editorial, accompanying the first publications, the editors highlight their views of open access including how they hope to respond to the high initial costs for authors.

They write: "ARIC's choice of "open-access" is a logical step towards its goal to be truly international and to allow the transfer of knowledge and best practices to even remote places that cannot afford printed journals. We realize that open access has financial consequence for some authors and that the standard BioMed Central rules to waive article-processing charges may not be enough. BioMed Central provides an automatic waiver to authors based in any country classified by the World Bank as low-income or lower-middle-income economies, but we intend to find solutions in the near future that will allow us to support authors from upper-middle income countries and young investigators"

The second and I think equally important reason that ARIC's emergence is important is that we've never had an international voice in infection control. As the 1200 attendees from 84 countries at last summers ICPIC meeting can attest, international collaboration will be the key for controlling antimicrobial-resistant bacterial pathogens (think NDM-1) in the future.

I wish the editors and the ARIC journal much luck and future success!

@eliowa

Orphan-drug funding crowding out antibiotic discovery?

2012-01-25T16:14:00.003-05:00

There's an interesting story today by AP Health writer Matthew Perrone that delves into reasons why little is spent on antimicrobial drug discovery in the US. His hypothesis is that funding for orphan drugs is crowding out antibiotic drug discovery in the private sector, forcing the US Government into action. The evidence offered is compelling, including the fact that 11 of the 30 new drugs approved last year were for rare medical conditions, the highest level since FDA incentives began about 30 years ago. These incentives include extra patent protections, higher pricing and a streamlined FDA review. The results speak for themselves: the first new SLE therapy in 50 years and first new Hodgkin's therapy in 30 years.

However, the evidence that this is actually spurring US-government funded antimicrobial drug discovery is weak. We're offered the somewhat misleading fact that "since 2006, government spending on research for familiar diseases like staph infections, smallpox** and botulism** has increased more than 660 percent, from $54 million to $415 million last year." OK...so what does this have to do with antimicrobial discovery?

To further highlight the dearth of investment in antibiotic discovery, we have this quote from Dr. Anthony Fauci: "We have pushed the envelope more toward diminishing the risk for companies so that they'll be more interested in getting involved with us and developing things like vaccines and antivirals." To be fair, he cold be talking about the mythical Staph vaccine. But seriously, whatever happened to "eschew obfuscation, espouse elucidation"?

The rest of the article highlights new investment in therapies for tularemia and agents of bioterror and new flu-vaccine manufacturing techniques. I had my hopes up for a minute.

**Note: There are on average 110 cases of botulism in the US every year and zero cases of smallpox. This compares to 19,000 DEATHS from MRSA per year, which would be at least twice that high if we included MSSA. Familar does not equal common.

Source: Matthew Perrone, SFGate (AP) 1/25/2012

A change of heart on vancomycin MICs?

2012-01-23T23:47:00.005-05:00

Last year I opined that using exact vancomycin MICs as a guide to antimicrobial selection for serious MRSA infections is not a useful exercise. This position wasn’t particularly controversial at the time, and is consistent with IDSA guidance.

However, I was just directed to this study in Clinical Infectious Diseases, in which the authors conclude that in patients infected with MRSA that have vancomycin MICs of 1.5 or 2 mcg/mL (by Etest, of course, which is the only way you’ll get an MIC of “1.5”), you should consider treatment with daptomycin rather than vancomycin. In response to this paper, apparently, a large tertiary care center lab was poised to begin testing all MRSA isolates with vancomycin MIC of 1 mcg/mL by Etest (to better detect these higher MIC strains).

Really? I will let Eli comment on the finer points if he wishes, but I’m confident stating that I wouldn’t rely on a single-center, retrospective, observational, Cubist-funded study to make a major change in laboratory or clinical practice. The potential confounders, measured and unmeasured, are legion. As a single example, ID consultation occurred twice as often in the daptomycin recipients than in the vancomycin recipients (64% vs. 32%). Now I believe that ID consultation does improve outcome—but even if it doesn’t, it’s probably associated with something that does.

Cubist is funding an RCT to address this question. I’ll be interested in seeing those results. In the meantime, I’m sticking with what I wrote last year, at least as regards the laboratory testing of MRSA.

Does #OpenAccess increase readership?

2012-01-23T23:22:00.000-05:00

From the "I Wish I Did This Study" department. Philip Davis and the American Physiological Society completed an RCT of the open-access publication model. All articles published in 11 APS journals between January and April 2007 were randomized into immediate free access (n=247) or normal subscription-only access for the first 12 months (n=1372). So did it work? Yes - far more downloads, same number of citations.

Article downloads: One-year after publication, open access articles received twice the number of full-text downloads and 61% more PDF downloads with more unique visitors. Fewer looked at the abstract with open-access, but why would they when they can read the whole thing? (see figure below)

Citations: Open-access articles were cited in similar numbers. During the first year, 71% of open-access and 74% of subscription articles were cited at least once. At three years, citations averaged 10.6 per open-access and 10.7 per subscription-based article.

My only question. Why was this published in a newsletter and not a peer-reviewed journal?

Reference: PM Davis. Physiologist. 2010 Dec;53(6):197, 200-1.

Yes, I know this discussion isn't specific to infection prevention, but it is a "controversy" so I'm at least partially sticking to our mission. (insert emoticon)

#openAccess Costs Less: Think about it.

2012-01-23T11:30:00.001-05:00

There are a few good examples as to why we continue to submit papers to non-open access journals. Sure open-access publication costs are high, but many researchers, even the under-funded hospital epidemiologist, should be able to gather up Departmental, Divisional or other resources to pay the publication costs. I think it's a matter of choice. Importantly, even if the research is called "unfunded", it is likely receiving hidden funding through paying of fellows' salaries or the opportunity-costs of less time spent actually doing "infection control." That is to say, someone is paying for the research.

"An implicit although obvious subtheme of Moneyball is that resistance to innovation is driven by job insecurity" - Nate Silver

There is a new article in the Atlantic by Laura McKenna that further describes the situation, and I think it's worth a close read. She describes the status quo very accurately:

1) Academic research is funded by national grants and/or subsidized through the university or hospital and the scientist is given "release time" to conduct the research.

2) The paper is then submitted to an academic (non-open access) journal.

3) These journals are housed and subsidized by universities (think ICHE and University of Michigan or AJIC and Columbia).

4) Journals are then edited by faculty members, who spend subsidized time editing the journal for not enough $$ to cover their time.

5) The "home" university provides offices for the editorial faculty and staff.

6) Papers selected for review are sent to faculty at other universities and are thus subsidized by these other universities, who support their peer-review activities.

7) If accepted, the manuscript is further reviewed by the editor and sent to the journal for publication

8) The publisher, to cover printing costs, sells the rights to JSTOR or other services and makes a tidy profit.

9) JSTOR then sells the papers back to university libraries for huge fees; said to be $45,000 initially and $8500/year just for the arts and sciences collection at JSTOR. If the general public (or non-university affiliated ICP) wants to read the article, they have to pay perhaps $38 to read it.

I will directly quote from her conclusion: "Step back and think about this picture. Universities that created this academic content for free must pay to read it. Step back even further. The public -- which has indirectly funded this research with federal and state taxes that support our higher education system -- has virtually no access to this material, since neighborhood libraries cannot afford to pay those subscription costs."

I would say that ALL of these costs, both visible and hidden, dwarf the one-time publication fee and would suggest that the reason we publish is to communicate our important findings with a wide audience. If universities can't support open-access publication fees to the extent that they already silently fund closed journals, and I would suggest if they did, the pub costs would drastically decline, then I wonder if the research is even worth doing. We easily spend 10 times more time (and money) collecting and analyzing the data, but can't cover the publication fee? Hogwash.

Dollars for Doctors

2012-01-22T18:09:00.001-05:00

The NPR show On the Media aired a very interesting story today on the pharmaceutical industry's use of gifts and payments to physicians to influence drug prescribing. What I like about this interview of ProPublica journalists is that you get a sense of how nonmedical people view this issue. You can listen to the podcast here and see ProPublica's webpage on this topic here.

In the realm of infection prevention, the industries are different (e.g., microbiologic diagnostic testing supplies and equipment, cleaning products, and antimicrobial/antiseptic coated devices), but the core issue is essentially the same--allowing industry to influence practice and policy by targeting individual practitioners, professional societies and lawmakers.

Photo: ABC News

A silver lining?

2012-01-21T18:26:00.000-05:00

The Journal of Infectious Diseases has a paper (free full text here) and editorial on statins and influenza. It's another observational study that finds that treatment with statins is associated with decreased mortality in persons with influenza. Over 3,000 laboratory confirmed cases of influenza requiring hospitalization in 10 states were analyzed in this study by CDC investigators. Treatment with statins was associated with a 41% reduction in mortality when adjusted for age, race, comorbid conditions, influenza vaccination and treatment with antivirals.

So when I take my dose of simvastatin tonight, I'll try to remember that this little pill may keep me alive when the next influenza pandemic hits. And speaking of flu, it's been a very slow season so far. At my hospital we've had only 2 confirmed cases, and those were in November.

Photo: Eastern Connecticut State University

Worthing Hospital: No #MRSA for 1 year!!!

2012-01-21T13:25:00.000-05:00

Worthing Hospital, a 500-bed District General Hospital in Worthing, West Sussex, England is celebrating a nice achievement: No MRSA for one year. How did they achieve success? According to this article, "infection control has become a priority for the trust...and has seen improvements such as an increase in cleaning rounds and extra training for the housekeeping staff, detailed root cause analysis of any MRSA case, investment in all levels of nursing and a highly qualified team of infection control specialists, who work with ward staff to ensure they always follow the best practice." The hospital also reports no C. diff in November.

For me, the article is most interesting for the picture and what they don't say. No mention is made of active surveillance cultures and they don't seem to be showing off nares swabs in their photo. It all seems rather horizontal-ish. High fives Worthing Hospital!

Antibiotic-free pork ≠ #MRSA-free pork

2012-01-20T13:27:00.000-05:00

Ashley O'Brien in Tara Smith's UI lab has a new study out in PLoS ONE looking at MSSA and MRSA in fresh retail pork samples. Tara has a comprehensive blog post covering this study and their prior work leading up to this paper, so check it out if you want a lot of the details.

Briefly, they collected 395 samples from 36 stores in IA, MN and NJ. 300 samples were from "conventional" pork and 95 were from pork labeled "raised without antibiotics." S. aureus was found in 67% of conventional samples and 57% of antibiotic-free samples, while 6.3% of conventional pork and 7.4% of antibiotic-free pork were contaminated with MRSA.

This is a relatively small study, so it likely should be repeated. Also, as Tara mentioned in her post, in the states included in this study, very few USDA-certified organic products were available unfrozen, and they targeted sampling of fresh meats. It is hard to speculate why MSSA and MRSA didn't differ significantly between the types of pork, but contamination during processing or at retail is certainly possible. Could it be that conventional and antibiotic-free pigs are raised in close proximity?

O'Brien AM et al. PLoS ONE January 2012

Hand over your money or I'll give you #MRSA

2012-01-19T14:07:00.002-05:00

From the truth is stranger than fiction department: A man walked into Lucky's Internet Cafe in Sharon, Pennsylvania on Monday and began touching everything in the place before walking up to the cashier. He then threatened to give the cashier MRSA if he didn't hand over the money.

The cashier refused, the man left and was later arrested at a Rite Aid Pharmacy across the street - no doubt attempting to fill his clindamycin script. I suspect the cashier was armed with bottle of alcohol hand rub under the counter, but this is just a guess.

Washington Post 1/19/2012

Sharon Herald 1/18/2012

Sunshinism: Protecting Patients or Further Destroying Physician Trust?

2012-01-18T15:08:00.008-05:00

Yesterday, Dan posted about the new rules mandating the reporting of all physician payments from drug and device manufacturers. Generally, I've been in favor of increased transparency if, as Dan said, the "information is detailed and accurate." However, I think any system like this can and will be gamed and I suspect the results will be more destructive than constructive. For example, funding for "research" is thought to be less conflicting than direct payments to physicians for giving canned talks. However, what about "research" support that pays for each patient enrolled and what if that payment goes directly to the enrolling physicians pocket, as would be the case in private practice? Is this such a bad thing that it needs to be constrained?

I suspect there are many other examples of how we won't be able to interpret the reports that are generated from these new rules. I even suspect that the eventual approach to determining financial conflicts will be through opening up every physician's tax return. That way, we can look at the true financial impact to the individual. Pharmaceutical research that goes to a university and doesn't directly increase a physician's deans-approved salary would thus not appear on a tax return. What about physicians that own stock in Pharma? Wouldn't that be a more important conflict? You can see where this is going. So someday soon, all physicians will have to share their tax returns with their patients perhaps by posting them in their waiting rooms or websites.

However, do you really think this will help root out conflicts? What are the negative externalities of such an approach? I suspect it will root out the caring physicians who don't want to appear to be in the pocket of pharma even if they are involved in highly important clinical studies. Which gets me to why I've been moved to write this post...

In today's NYT, David Brooks and Gail Collins debate the call to release Mitt Romney's tax return. In the column, Brooks makes some important points, which I think are worth at least pondering in regards to the new payment disclosure rules and other examples of "sunshinism."

Brooks: "...there is a misbegotten ideology haunting the land, the ideology of sunshinism. This is the belief that everything should be made public. Sunshinism is a destructive ideology. Forcing people to financially undress in public is just one of those incursions that repels decent people..."

Could these new rules further mistrust of the medical community? Is society better off when a patient doesn't want see an ID doc because she made $5000 enrolling patients in a trial of a new antibiotic? If she won't enroll patients, who will?

Which is a greater conflict for a physician? (a) $50,000 investigator initiated grant to a University (b) $5000 direct payment for giving a canned talk (c) $5000 for enrolling patients in a trial or (d) $50,000 stock in a pharmaceutical company that won't be disclosed under the new rules?

OK, so I think I've built a solid enough straw man.

La Nina and Influenza Pandemics

2012-01-17T14:23:00.000-05:00

A new study published in PNAS by Jeffrey Shaman and Marc Lipsitch finds that the four recent influenza pandemics (1918, 1957, 1968, and 2009) were all preceded by La Niña (colder sea surface) conditions in the Pacific Ocean. The authors suggest that the climate changes can alter migratory bird activity and thus possibly impact their mixing with domestic animals. They therefore hypothesize that La Niña results in a higher likelihood of divergent influenza subtypes coming together with a subsequent higher probability of emergence of novel "pandemic" influenza strains.

In an accompanying BBC story by Richard Black, professor Shaman explains the findings and also cautions that the link should not yet be used to predict pandemics. However, he is hopeful that increased influenza strain surveillance subsequent to recent novel H1N1 and avian H5N1 activity will soon be able to confirm whether their proposed hypothesis is correct.

Reference
Shaman and Lipsitch PNAS 1/17/2012

@eliowa

This should be interesting...

2012-01-17T00:00:00.000-05:00

New rules that mandate reporting of all physician payments from drug and device manufacturers should be out soon. I favor this transparency, provided the information is detailed and accurate. For example, receiving money from a company for doing a valid research study on one of their products is a bit different than receiving money to travel around the country on a speaker’s bureau. Let’s hope the publicly available data includes information about the reason for the payment, and the recipient of the payment (e.g. the medical school, to support Dr. X’s research study, or directly to Dr. X).

It will also be interesting to see if makers of diagnostic devices will be included—clearly the makers of devices that touch or are inserted into patients will be required to report payments, but it isn’t clear to me if the same holds true for makers of new diagnostic tests. As we’ve discussed before in this blog, such transparency is also extremely important.

Gaming of Impact Factors: New tactic or did they just get caught?

2012-01-16T10:04:00.000-05:00

Ben Goldacre, one of this blog's favorite journalists/authors/doctors/critics, has a fascinating new post up on his secondary blog. We all know that a journal's impact factor is largely useless for grading the quality of an individual paper. This follows from the old idiom, that you can't judge a book by it's cover. However, impact factors are also a poor way of comparing the quality of journals themselves. For one, journals that contain many review articles have higher impact factors since reviews are cited more frequently than original research. Journals game their impact scores by publishing more review articles. Now there is evidence that editors are gaming impact scores by forcing authors to cite articles from their journals before accepting the paper! Craziness.

The evidence from a revise and resubmit letter: “The Editors would also greatly appreciate you adding more than two but fewer than six references of articles published in [the Journal involved], above all articles published over the past two years.” Even more evidence that you can't judge a book by the cover.

I would write more, but I gotta go round, so I leave it to Mr. Bo Diddley...

references:
(1) Ben Goldacre Secondary Blog - 16 January 2012
(2) F. Avanzini et al. Journal of Thrombosis and Haemostasis

Science Friday (the 13th): TDR-TB

2012-01-12T21:21:00.001-05:00

Maryn McKenna (@marynmck) of Superbug fame will be on Science Friday (Hour 1: 2-3pm ET) tomorrow to discuss Totally Drug-Resistant TB. She has had some very informative posts recently on the topic, including discussion of the two earliest known patients in Italy who died in 2003. She also reports on the latest twelve TDR-TB cases in a single Indian hospital and points us to an ahead-of-print letter in CID posted in December that discusses the diagnosis and care of the first four of these patients in India. Turn on, tune in...

Superbug post #2: Earliest Cases of TDR-TB
Superbug post #1: Latest Cases of TDR-TB in India

(Eli @eliowa)

Support open access!

2012-01-11T16:13:00.000-05:00

There is an excellent OpEd piece in today's New York Times by Michael Eisen, one of the founders of the Public Library of Science. A few years ago, the NIH mandated that any studies performed that were federally funded must be made available free of charge to citizens since they had paid for the research through their tax dollars. This obviously had an impact on journals that use the traditional business model of publishing, wherein the reader bears the cost of publication via subscription, either individually or through a library. Several years ago, the open access model of publishing emerged. In this business model, the cost of publication is borne by the author, often via funds from the research sponsor. However, papers published in this model are free to the reader.

The OpEd piece today points out that some notable journals in the traditional publishing model, including the New England Journal of Medicine, are now lobbying Congress to pass a law reversing the NIH rule so that they would no longer be required to make the papers available at no cost to readers. In response, Dr. Eisen calls on researchers to publish their studies only in open access journals and for libraries to cancel their subscriptions to journals that are not open access. The greed demonstrated by journals that are financially healthy is unpalatable. However, open access is a problem for investigators who publish papers that do not have a funding source, since the publication fees are often in excess of $1000 per paper. This is particularly a problem for hospital epidemiology, a field in which much research is unfunded, and is likely one of the reasons that the open access journal Antimicrobial Resistance and Infection Control has had a slow start. Open access is clearly a great concept and it should be maintained for studies that are federally funded. And for those of us who believe that medical and scientific research is a public good, further expanding open access by reducing or eliminating authors' fees via novel approaches is a worthy goal.

Tragedy of the commons: Antibiotics in Agriculture

2012-01-11T10:36:00.003-05:00

@marynmck broke the story right before Christmas that FDA had silently posted that they are backing-off of their long-held (1977) plan to limit overuse of agricultural antibiotics. Instead of formal bans and policy change the FDA now hopes to “focus its efforts for now on the potential for voluntary reform and the promotion of the judicious use of antimicrobials in the interest of public health.”

So here is the current US policy for protecting a critical and diminishing resource for public health: Please Please Please don't use antibiotics! Please? How about if I'm nice? No? Pretty Please. Sugar on top? Perhaps we should call this the "Don't let the Pigeon Drive the Bus Policy." I guess it kinda worked in the book. Kinda.

So after burying the bad news on a Thursday before a major holiday weekend, the FDA posted some sort of half-good news right after the new year. You guys excited? So what was the good news? They will limit cephalosporins (woo woo) but with so many loopholes and restrictions that it won't matter much. Today, a NYT Editorial in frustration pointed out that FDA "will ban the injection of the antibiotics into chicken eggs and halt the practice of giving large, sustained doses to cattle and pigs. But it still allows widespread use in animals like rabbits and ducks, and veterinarians will still be able to use the drugs in ways not specifically approved by the FDA."

We've written about this issue many times before. It's amazing that we continue to squander critical antibiotics in animal populations, while at the same time barely funding efforts to develop new antibiotics or new infection prevention strategies. The NYT stated today that "it’s time for the FDA to consider the public’s health as carefully as it considers the interests of intensive agriculture and pharmaceutical companies." Hear Hear.

Sources:

1) Maryn McKenna, Superbug Blog 12/23/2011
2) NYT Editorial "FDA Creeps Forward" 1/11/2012

Break-bone Fever in the Conch Republic

2012-01-10T18:21:00.000-05:00

Key West by Kerne Erickson

I love Key West! With its predictably warm weather (even in January!), its lack of pretentiousness, and its welcoming attitude, what is there not to like about this little island? Well, apparently there is one thing: the latest issue of Emerging Infectious Diseases has a paper (full text here) on the reemergence of dengue in Key West.

Three clinical cases of dengue were acquired there in 2009, which prompted the CDC to investigate further. A serosurvey done in September 2009 showed that 3-5% of residents in the Old Town area had been recently infected. In 2010, an additional 63 clinical cases were reported.

I guess I'll have to take along some mosquito repellent next time I head to Margaritaville.

Hospital + fountain = trouble

2012-01-09T20:50:00.001-05:00

Photo: Urban Review STL

A report in this month's Infection Control and Hospital Epidemiology describes an outbreak of Legionellosis involving 8 patients who ended up hospitalized at two hospitals. Via good old fashioned shoe leather epidemiology, it was determined that the only common exposure among these patients was exposure to a hospital with a wall-type water fountain in the lobby. Environmental cultures revealed that the fountain was heavily contaminated with Legionella pneumophila serogroup 1. A few years ago, Dan blogged about another Legionella outbreak associated with a indoor fountain in a hospital. If your hospital has one of these, shut it down!

The long road to fast and accurate resistance detection

2012-01-09T00:42:00.004-05:00

I’d like to say that molecular diagnostics will soon provide nearly instantaneous detection of antimicrobial resistance in clinical samples, allowing for rapid targeting of appropriate therapy. I’d like to say that, but I can’t. Even MRSA, a bug with a relatively simple resistance mechanism (simple relative to, say, MDR Acinetobacter), is proving to be a tough nut to crack. Remember this post of mine, about Cepheid’s recall of their Xpert SA/MRSA blood culture assay? Well, another “valued customer” notice went out last week, informing users that this product requires “additional test optimization” and “clinical re-validation”—so it will be unavailable until at least the end of 2012. Labs and hospitals that have come to rely on this test to improve their antimicrobial management of S. aureus bacteremia will now have to find another approach.

I’m posting not to knock Cepheid, but to make the point that bringing new rapid diagnostic methods to a clinical microbiology laboratory environment, and applying them to clinical care in unforgiving situations (e.g. would you like to have your MRSA bacteremia treated with nafcillin for the first 2-3 days?) is difficult! The makers of agar plates will be keeping their day jobs for a while….

Quote of the Day

2012-01-05T17:32:00.000-05:00

Ezekiel Emanual (U Penn) wrote an Editorial in this weeks JAMA titled "Where are the Health Care Cost Savings?" where he suggests that there are not enough aggregate savings in targeting malpractice costs, insurance profits, drug costs, and the "million dollar babies" to make a significant impact in US medical expenditures.

Where does he think the savings are:

"One estimate suggested that as much as 22% of all health care expenditures is related to potentially avoidable complications...reducing avoidable complications by 10% could save more than $40 billion per year."

The reference for the 22% estimate is a 2009 article by François de Brantes et al in the NEJM. What was the preventable complication example in the 2009 article? A readmission for a harvest site SSI post-CABG.

Video of the day

2012-01-05T12:23:00.000-05:00

Here's a short video from a great organization, Clean the World. They collect leftover soap and shampoo from hotels, recycle it, and take it to those who need it in the developing world.

Chart of the day

2012-01-05T11:25:00.000-05:00

The graph here shows the yearly number of publications found via a PubMed search using the terms "MRSA" and "active surveillance." What this means is open to interpretation, but I do sense that some of the fervor for this practice may be waning.

Death of the Mid-Career Investigator

2012-01-05T08:00:00.009-05:00

Now that we Iowans have failed to select a candidate in the GOP caucuses, we can turn our attention to other political pursuits. There is an important article just released in PLoS ONE by Kristin Matthews and colleagues at Rice University that describes the aging of the biomedical-research community in the US and its potential impact.

The authors report that the average age of an NIH investigator rose from 39 to 51 between 1980 and 2008, while the average age of a new (first time) investigator rose from 36 to 42 during the same period. They also make some interesting comparisons to the average age of Nobel Laureates to determine if the rising age barriers at NIH could impact future innovative ideas and research. They found that during the same period, 96 scientists won a Nobel Prize in medicine or chemistry for biomedical research at an average age during the awarded research of 41 and 78% completed their research before age 51. They suggest that scientists do great work early in their careers but now those early careers won't be funded.

They conclude that "if nothing is done to reverse the rising age of PIs and first-time grantees, the scientific community could lose a generation of researchers, leading to an unsustainable biomedical research infrastructure and a dearth of talent participating in NIH-funded projects in the near future." I think a similar problem exists in infectious diseases and infection prevention research.

A world filled with only postdocs (source Matthews et al PloS ONE)

Thus, there appears to be little funding or opportunity in the early and particularly mid-career period. This results in many fine and well-trained investigators leaving biomedical research in their 40's and never returning. Sure, a few lucky people will survive this pyramid scheme, but there won't be enough senior investigators in 10-20 years to mentor the next generation.

I'm not sure what the solution is or even the exact problem. Is it ageism in scientific review committees or the lack of tenure-track faculty positions at the University level? I suspect both of those issues are intertwined.

Source: Matthews et al. PLoS ONE 12/28/2011

Hospital epidemiologists are killing pharma

2012-01-04T14:02:00.000-05:00

Photo: 2old2play. com

A new report shows that the hospital acquired bacterial infections market for the time period 2010 through 2017 is expected to decline by a negative CAGR of 3.4% (click here if, like me, you need help understanding a CAGR). One of the major reasons cited for this decline in the market for these antibacterial drugs is a reduction in healthcare associated infections.

If you are interested in learning more about what's in this report, click here and submit your credit card information. For only $3,500 (about the same price as a course of fidaxomicin), the report can be yours.

Happy New Year from #Iowa #Nice

2012-01-03T18:24:00.000-05:00

I think infection control was also invented in Iowa...

Treatment as prevention; or, the best defense is a good offense

2012-01-01T20:39:00.003-05:00

The journal Science has selected this paper as their “breakthrough of the year”. As you know, the HIV Prevention Trials Network study 052 demonstrated that early antiretroviral therapy reduced heterosexual HIV transmission by 96%. The concept is intuitively obvious, but often we compartmentalize “prevention” and “treatment” without recognizing how crucial prompt and effective therapy can be to preventing pathogen transmission (and/or to preventing emergence of antimicrobial resistance). I suspect we can and will put together some excellent sessions on “treatment as prevention” at the inaugural ID Week in 2012.

Oh, and Happy January 2012 from this humble blog.

What do sinks & contact lenses have in common?

2011-12-29T19:11:00.000-05:00

Fusarium macroconidia
Photo: Farm Life Sicilia

Every infectious diseases doctor hates Fusarium, as therapeutic options are limited and relatively ineffective. I suspect the ophthalmologists do too, since Fusarium can cause severe keratitis in contact lens wearers.

This month's issue of Journal of Clinical Microbiology has an interesting study, funded in part by Bausch and Lomb (the maker of a particular contact lens cleaning solution that appeared to be associated with cases of Fusarium keratitis), on detecting the environmental source of the organism. Like many of the pathogens that infect profoundly immunosuppressed patients, Fusarium is also found in the environment, but unlike many other opportunistic fungal pathogens, it doesn't enter the body via the respiratory tract.

Investigators in this study sampled nearly 500 drains, primarily of bathroom sinks in 7 eastern states as far north as Pennsylvania, as far south as Florida, as well as California. They found that 66% of sink drains harbored Fusarium. Moreover, the most common strains detected are the most common strains that cause clinical infections. Importantly, this organism produces and lives in biofilm, which not only coats your sink drain, but can coat your contact lenses when they are inappropriately cleaned.

Two papers linking XMRV and chronic fatigue syndrome retracted

2011-12-27T14:01:00.001-05:00

Mike posted on a paper refuting the possible link between XMRV and chronic fatigue syndrome over a year ago. Now it appears that both the 2009 Science paper and 2010 PNAS paper supporting such a link have been retracted. The reasons for retraction of each paper appear to be very different. For example, the story of the Science paper authors' possible image manipulation described by blogger Abbie Smith is pretty fascinating. A great description of both retractions and related media reports can be found for both the Science and PNAS paper at Retraction Watch. All of this is very unfortunate for the scientific community and especially the affected patients.

Sources:

Retraction of Lombardi et al., Science 326 (5952) 585-589 in Science 23 December 2011: Vol. 334 no. 6063 p. 1636

NY Times, David Tuller 12/26/2011

h/t Ivan Oransky at Retraction Watch Blog 12/26/2011

Scientific inquiry, biosafety, and censorship

2011-12-21T23:01:00.007-05:00

Investigators at the University of Wisconsin and at Erasmus University in the Netherlands have modified the H5N1 avian influenza strain so that it is not only highly virulent but also can be efficiently transmitted (at least among ferrets). Since the release of such a strain (high lethality, high transmissibility) would set the stage for a real-life version of the movie Contagion, there has been some high level angst about the wisdom of publishing the details of these experiments. This is kind of a big deal now, with a U.S. government panel appealing to two high-profile scientific journals (Nature and Science) to keep the experimental details out of the published reports of these experiments.

It appears that the scientists and institutions involved will comply with the recommendations of the National Science Advisory Board for Biosecurity. However, this work has already been presented at open scientific meetings, and detailed articles have been sent for peer review. And as Ron Fouchier, the lead investigator at Erasmus, says in today’s NY Times, “as soon as you share information with more than 10 people, the information will be on the street.” Finally, one purpose of the work was to identify those mutations that lead to greater transmissibility, so that they can be quickly detected during surveillance to help guide prevention efforts. I don’t think this can be done while simultaneously keeping those mutations a secret.

Contact precautions, and why I hate them, holiday edition

2011-12-19T21:51:00.004-05:00

Investigators at the University of Maryland (and one or two who used to be there) are among few who are carefully examining the unintentional adverse consequences of contact precautions. Their latest publication comes out in January’s ICHE. In this paper, they report an association between starting contact precautions during hospitalization and delirium.

After adjusting for comorbid conditions, age, sex, ICU status, and length of stay, Day and colleagues found that patients newly placed under contact precautions during hospitalization were more likely to experience delirium (odds ratio 1.75, 95% CI 1.6-1.9). Delirium was defined by ICD-9 code, supplemented by use of restraints and anti-psychotic meds (this measure was validated by randomly-selected chart review). Curiously, this association did not hold for patients admitted to the hospital under contact precautions. As the authors point out, those admitted under contact precautions weren’t nearly as sick as those newly placed under precautions during hospitalization, which may account for this difference.

I’ll be the first to point out that this study doesn’t prove causation—however, the study does support our previous recommendations that patients placed under contact precautions should be carefully monitored for adverse psychiatric consequences.

Congratulations, Mike!

2011-12-16T12:59:00.007-05:00

On being selected by HealthLeaders magazine as one of their 2011 “HealthLeaders 20”, twenty individuals they consider to be “changing healthcare for the better”. Mike’s profile can be found here. And yes, I found a photo of him wearing a tie.

No White Coats in Miami!!

2011-12-16T12:44:00.001-05:00

I know it never gets cold in Miami, so they have one less excuse to hear from clinicians, but we wanted to share with you a new practice at Jackson Memorial Hospital in Miami, Florida. Silvia Munoz-Price, Medical Director for Infection Control, shared that this past month they have found that white coats and scrubs were contaminated with the same pathogens as found on the hands of providers wearing the coats/scrubs. Thus, for the past 2 weeks they have been doing ID rounds wearing scrubs or bare below the elbow and without white coats. They report receiving "no negative feedback from the staff nor patients." Way to go Team Miami!

Failure of Freakonomics

2011-12-15T16:00:00.004-05:00

Andrew Gelman (Columbia) and Kaiser Fung (NYU) have an interesting article in the Jan/Feb 2012 issue of American Scientist that is worth a read. They review the popular Freakonomics franchise of Steven Levitt and Stephen Dubner. Freakonomics and SuperFreakonomics have set the standard for the popular statistics/economics genre, from which Gelman and Fung have both benefited. (click on their names to see their books)

However, Gelman and Fung have identified a "tendency in the Freakonomics body of work to present speculative or even erroneous claims with an air of certainty." Overall, I'm not so worried about the small errors they outline, but the reasons for the errors are concerning and the solutions are important ones to consider in any scientific discipline, including healthcare epidemiology.

One major problem they identify is Levitt and Dubner's reliance on linear informal social networks. For example, in the original Freakonomics, the network was "Levitt did the research, Dubner trusted Levitt, the Times trusted Dubner." However, as time pressures built and the need for more unique stories increased in SuperFreakonomics the network devolved into "Levitt trusts brilliant stars such as Myhrvold or Oster, Dubner trusts Levitt, and we the readers trust the Freakonomics brand."

The solution offered was that they should "leave friendship at the door." I think this is something all scientific disciplines could benefit from. It is clear that editorial boards, grant review committees and annual meeting planning committees are all at risk from reliance on a "linear" closed social network (in the past called "old boys' network"). They suggest that building more "non-linearity" into their research and evaluation would protect the process from what I might call a "friendship" bias. Excellent advice, perhaps difficult to put into practice, but worth the effort.

link: American Scientist Jan/Feb 2012

The iPatient and patient safety

2011-12-15T09:27:00.003-05:00

Last December Mike published a piece in the Annals of Internal Medicine about how care delivery has changed on medical teaching services, including the reduction in physician interaction that now occurs as a result of residency hour limits and of the computerization of health care delivery. Residents and fellows now spend hours per day sitting in front of computer terminals, from which they must complete nearly every task (except, you know, actually seeing a patient, when telemedicine is not an option).

The NY Times has an article today on another unintended consequence of our increased reliance on computers and handheld devices—distracted doctoring. Distractions come not just from our obsession with what Abe Verghese calls the “iPatient” (that wealth of digital data each patient accumulates during even a short hospital stay), but also when we use devices for non-patient related activities during rounds, in the operating room, etc. Read the piece for yourself, and decide if this anecdotal problem is a real issue for patient safety (and if so, how to measure it, and how to implement change, when computers have become so essential for patient care). My favorite quote in the piece:

“The iPatient is getting wonderful care across America,” Dr. Verghese said. “The real patient wonders, ‘Where is everybody?’ ”

If Air Travel Worked like the US Healthcare System

2011-12-15T00:38:00.001-05:00

Somehow, this makes me like air travel for the first time in 10 years...

h/t @IrfanDhalla via @picardonhealth

Patient Zero - Typhoid Mary through HIV

2011-12-13T10:52:00.000-05:00

WNYC's Radiolab typically covers scientific and philosophical topics. I just listened to their recent show/podcast titled "Patient Zero", which was fantastic. They start off discussing Typhoid Mary - the iconic Patient Zero. They tell 'the rest of the story', which I would guess that most of us haven't heard before. They then trace the molecular epidemiology of HIV back to a mystic first transmission to humans in Africa. They finish up with a discussion of the first ever High Five. It seems that high fives are even more infectious than infectious diseases. High fives all around.

Source: November 14, 2011 Radiolab podcast: "Patient Zero"

IDWeek Rejected Session

2011-12-12T16:52:00.000-05:00

Dan and I are in DC today for the IDWeek Program Planning Committee meeting. Of course, we can't discuss actual sessions, so I thought of a fake session to get you excited for the 2012 joint meeting.

Session Title: Infectious Disease Issues on Sesame Street

Stop Blaming the Birds: From West Nile to Avian Flu - speaker: Big Bird

Risk factors for "Red Man Syndrome" - speaker: Elmo

Salmonella Typhimurium and Water Frogs - speaker: Kermit the Frog

Y. pestis or Francisella tularensis in Prairie Dogs - speaker: Prairie Dawn

Stephen Colbert on chickenpox lollipops and fecal transplants

2011-12-11T10:02:00.000-05:00

The Colbert Report

Mon - Thurs 11:30pm / 10:30c

Cheating Death - Chicken Pox Lollipops & Fecal Transplants

www.colbertnation.com

Colbert Report Full Episodes

Political Humor & Satire Blog

Video Archive

S. aureus decolonization: Review of the benefits

2011-12-10T19:00:00.000-05:00

In the December 2011 Lancet ID, Andrew Simor from the University of Toronto reviewed articles listed in PubMed from 1989-2010 assessing the benefits of S. aureus decolonization. There were no surprising results. In fact, most of the conclusions were hedged. For example he says that "some data support the use of decolonisation in surgical patients colonised with S aureus, particularly in those undergoing cardiothoracic procedures" and "patients undergoing chronic haemodialysis or peritoneal dialysis might benefit from decolonisation, although repeated courses of treatment are needed, and the effects are modest." The hedging is not a criticism of the author, but rather due to the lack of funding for proper infection prevention studies. What is surprising is that this is a single-author paper. Any systematic review should be completed by more than one author, in my opinion. Another limitation is the lack of summary odds ratios. However, this is a very good literature review and a wonderful resource.

Source: Simor AE, Lancet ID December 2011

Some norovirus with your entree?

2011-12-10T07:40:00.001-05:00

We've blogged before about the problem of presenteeism in healthcare workers. We've all seen coworkers come to work sick and maybe have even done that ourselves. But from a public health perspective, presenteeism isn't just a problem for doctors and nurses. Those who work in the food service industry can spread gastrointestinal and other infections when they come to work sick. And they are very likely to work while sick. An article in the latest issue of The Progressive points out that 80% of food servers in the US lack paid sick leave. The Restaurant Opportunities Center United (ROC) in a survey (below) of 4,300 food service workers found that nearly 2/3 of these workers prepared or served food while sick.

ROC has also published a diners' guide (full text here), which includes information on which restaurants do and do not provide paid sick leave for their employees.

More on fecal transplants

2011-12-09T08:47:00.001-05:00

Maryn McKenna has two new pieces on fecal transplants on her blog and in the latest issue of Scientific American (full text here). These are very well written. I plan to use these for patient education when I see patients with recurrent Clostridium difficile infection for whom fecal transplantation may be an option.

Best news ever! A Norovirus vaccine that works!

2011-12-08T16:37:00.003-05:00

As a parent or two young kids, I dread the slightest hint of nausea. Now, perhaps, I might have one less pathogen to fear and perhaps in old age, I can even take a cruise.

In the recent NEJM there is a report of an RCT assessing the safety, immunogenicity, and efficacy of an intranasal norovirus viruslike particle (VLP) vaccine. The study was conducted in adults aged 18 to 50. They received two doses of either vaccine or placebo and were subsequently inoculated with Norwalk virus during an inpatient challenge with 10 times the infectious dose and monitored for infection and gastroenteritis symptoms for a minimum of 4 days. (No way I'd ever volunteer for this study)

The study included 98 patients with 90 completing both injections. A Norwalk virus–specific IgA seroresponse was found in 70% of vaccine recipients. This level of response is similar to my old Maryland colleague Samer El Kamary's 2010 JID paper that showed a 79% response rate. Vaccination significantly reduced the frequencies of Norwalk virus gastroenteritis (occurring in 69% of placebo and 37% of vaccine recipients, P=0.006) and Norwalk virus infection (82% of placebo and 61% of vaccine recipients, P=0.05). Not perfect, but still a great result.

Note: These data were also presented at earlier IDSA (2010) and ICAAC (2011) meetings.

Source: RL Atmar et al. NEJM Dec 8, 2011

Update: This news is pretty good too. (Massive drop in in-hospital deaths...in Canada)

Deus ex machina (Part 4): Flavonoid-like Molecules

2011-12-07T14:16:00.001-05:00

Flavo-Noid?

When I started the Deus ex machina "meme" three weeks ago, I had no idea that so many potential novel antimicrobials would just suddenly appear. First we had tiny magnets, then we had DNA or RNA gold nanoparticles and now word comes that there is a newly synthesized family of flavonoid-like molecules with antibacterial and antifungal activity.

Fowler et al. in PLoS ONE examined flavonoids, which are abundant plant metabolites with anti-infective activity. They used a natural flavonoid scaffold to create novel flavanones and tested their efficacy versus E coli, B subtilis, Cryptococcus neoformans and Aspergillus fumigatus. They screened eight molecules and found that 4-chloro-flavanone was the most potent antimicrobial compound. What did Ralph Waldo Emerson say? I think it's that "We judge of man's wisdom by his hope." Keep hope alive.

Source: Fowler et al. PLoS ONE 2011

Via: Hampton T, JAMA 2011

Close the lid before you flush?

2011-12-05T15:09:00.001-05:00

Photo: Eljer Toilet Seats

A new study in the Journal of Hospital Infection evaluates what happens when a toilet that contains Clostridium difficile is flushed. Using air sampling and settle plates placed around the toilet, the investigators determined that the organism is aerosolized by the flush and could be found on most of the settle plates. Interestingly, if the toilet lid were closed prior to flushing, C. difficile could not be recovered from any of the settle plates. Unfortunately, hospital toilets typically don't have lids, and the investigators recommend that hospital toilets should be fitted with lids. However, this would mean that the undersurface of the lids would quickly become contaminated, which could also cause problems.

There's an old pearl bantered about by infectious diseases doctors that the world is covered with a thin veneer of stool. This study and the one I blogged about a few weeks ago surely provide proof of that.

Deus ex machina (Part 3): DNA Gold Nanoparticles

2011-12-03T13:34:00.001-05:00

Dr. Chad Mirkin

Yesterday, NPR's Science Friday had a discussion of a novel antimicrobial based a platform of spherical nucleic acids that have been developed at Northwestern. Dr. Chad Mirkin, director of the International Institute for Nanotechnology at Northwestern University, discussed the possibility that DNA or RNA gold nanoparticles could be designed to invade bacterial cells and "either turn off resistance so that a conventional antibiotic will work or, better yet, stop replication and ultimately cause bacterial cell death." Sounds pretty exciting and human trials are expected soon.

The most important thing mentioned was that DARPA, the research arm of the Defense Department, has called for development of new, next-generation antibiotics. You can see by the host Ira Flatow's comments (quotes below) that he is perplexed as to why the Defense Department is leading the charge.

FLATOW: "And why is it that DARPA has to jump in here? What's wrong with our own medical system?"

FLATOW: "So what you're saying is that the people are willing to spend money on the military to do this where they might not in the civilian case."

Transcript: Hitting The 'Off' Switch On Antibiotic Resistance

Listen to the program (NPR 12/2/2011)

Ethical Issues in Cluster-randomized Trials

2011-12-02T17:43:00.001-05:00

*Ottawa is in Canada

Infection prevention studies, particular ones that aim to prevent transmission of resistant pathogens (or influenza) are typically carried out at the population (e.g. ICU) level. Thus, the study design of choice is the cluster-randomized trial. The Ottawa Hospital Research Institute has recently held a conference and developed a set of documents highlighting the key ethical issues in these trials.

These papers cover topics such as: (1) Who is the research subject in cluster randomized trials in health research? (2) When, and from whom, is informed consent required in cluster randomized trials? (3) Does clinical equipoise apply to cluster randomized trials in health research? (4) Assessing benefits and harms in cluster randomized trials and (5) Cluster randomized trials in vulnerable populations. These papers have or will soon be published in the open-source journal Trials.

Source: OHRI CRT Ethics page

Breaking...bacteria are everywhere!

2011-11-30T22:34:00.004-05:00

As we recently found with our hospital curtain study, the media are fascinated with the fact that bacteria can survive on inanimate objects. The latest culprit, as outlined in this LA Times article, is paper. Paperless electronic medical records would seem a great solution to this problem, were it not for those germ-laden computer keyboards!

The solution is simple, fortunately. Just make sure that the last thing you touch prior to contact with a patient is an alcohol hand sanitizer.

Deus ex machina: duabus partibus (Part Two) - Tiny Magnets

2011-11-28T16:47:00.001-05:00

With infectious diseases, there is always another miracle around the corner. The problem is that the miracle typically stays around the corner. Come on down...The next contestants in the search for a miracle cure are..."tiny magnets."

Researchers in Switzerland are developing nanomagnets that could remove harmful compounds (e.g. bacteria) from the blood. The technology involves magnetized nanoparticles coated with carbon and pathogen-directed antibodies. The plan is that the antibodies attach to the pathogens and then the whole compound is removed from the blood with hemodialysis. Sounds pretty exciting. Probably exciting enough to hold off on further investments in infection prevention research, not!

Source: Technology Review (MIT): 11/28/2011

Taking hand hygiene monitoring to a new level

2011-11-25T08:55:00.001-05:00

Photo: Richard Lee, New York Times
CS = current shift; WR = weekly rate

A new study in Clinical Infectious Diseases details the use of video monitoring in North Shore University Hospital's medical ICU to improve hand hygiene compliance. Video cameras were placed in hallways and every patient room with remote video monitoring performed by observers in India.

In the initial phase of the study (16 weeks), no feedback was given to healthcare workers in order to determine the baseline rate of HH compliance, which was found to be incredibly low at 6.5%. In the second phase of the study (16 weeks), realtime feedback was provided by electronic boards (shown in the photo), with more detailed reports emailed to unit leadership 3 hours after start of each 12-hour shift and at the end of shift, as well as a weekly summary. During this period, hand hygiene improved to 82%. The third phase of the study (75 weeks, interventions identical to the second phase) showed the overall compliance rate to be 88%.

So here we have a very interesting study with compelling results. Unfortunately, the authors do not provide any data on infection rates. Given that we believe that hand hygiene and infection rates are linked, if any group were ever in a position to prove this dogma, it is these investigators with data on 400,000 hand hygiene opportunities over a 2 year period.

Some additional information on the study can be found in the Fixes blog at the New York Times web site. In that piece the cost of the surveillance system is delineated--$50,000 for the video equipment with $1,000 per month for "maintenance." We are not told if "maintenance" is the cost of the wages for the persons doing surveillance, who are employed by a company in the business of remote video auditing.

The authors point out that the healthcare workers were all informed that hand hygiene would be monitored, and all feedback was done at the aggregate level without identification of individual healthcare workers during the study. But I'm left with an uneasy feeling. It seems somewhat absurd to me to devote this level of resources to a single element, albeit an important one, of patient care. Even more absurd is that the real work is being done in a third-world country (whose public health infrastructure is so primitive that half of the population is forced to defecate in the open) by human observers making very low wages in order to make marginal improvements in the quality of care in an ICU setting (where a great deal of futile but incredibly expensive care is delivered) in the richest country of the world. I just can't wrap my arms around that juxtaposition.

I'm thankful for the CDC

2011-11-24T07:27:00.001-05:00

Last night, I stumbled across a link to this piece:

Somehow I read all the way through it before I saw who had written it. Then it all made sense. Like a bad penny, Betsy McCaughey, turns up yet again. Since it's a holiday and I would prefer to stay in a joyful mood, I won't write anything about her, but refer you here to see our previous postings about her.

So on this Thanksgiving Day, I'm thankful for the CDC. Over the course of my career, I have come to know many people who work there, particularly in the hospital infections group. They are simply a great bunch--smart, hard-working, dedicated people who do great work with little recognition. The CDC has been working in the area of healthcare associated infections for over four decades and it's difficult to imagine what healthcare epidemiology would look like today were it not for these folks.

In case you need another reminder to wash your hands...

2011-11-23T20:16:00.001-05:00

Photo: Medical Tips Blog

There's a new paper in PLoS One on the biogeography of public restrooms (full text here). In other words, some investigators cultured various surfaces in 12 bathrooms on a university campus and then mapped out areas where groups of bacteria (e.g., skin flora, gut flora, genitourinary tract flora, and soil organisms) were found. The results were quite predictable. Soil organisms were dominant on floor surfaces (brought in via shoes), skin organisms dominated on faucets, and fecal organisms dominated on toilet surfaces. Of note, toilet flush handles were found to harbor both fecal organisms and soil organisms, and the authors postulate that the soil organsims are deposited there when people flush toilets with their feet in order to avoid touching the flush handle with their hands.

Ironically, one of the sponsors of the study was the Howard Hughes Medical Institute, the foundation started by an infamous germophobe.

So for all of you using the bathroom in an airport, train or bus station on this Thanksgiving eve: Wash your hands! And turn off the faucet with a paper towel.

Paul Offit and the Dangers of the Anti-vaccine Movement

2011-11-23T11:36:00.001-05:00

Paul A. Offit, MD, talks with Eli Y. Adashi MD, Brown University and Medscape, about the history and hazards of the anti-vaccine movement. "Residual damage, 40% of parents are now delaying or withholding one or more vaccines from the children." You can read our prior posts on Dr. Offit here.

Collateral damage: The ongoing measles epidemic in Quebec.

Novel H3N2 Influenza in Iowa: More bad news from pig country

2011-11-22T22:44:00.005-05:00

PIGS: Portugal, Italy, Greece and Spain

When it rains, it pours. Dr. Patricia Quinlisk, medical director for the Iowa Department of Public Health, announced today that a novel H3N2 influenza A strain had infected three Iowa children. Evidence points to one child transmitting the virus to the other two. There have been seven prior cases of this strain, all in the US (Maine, Indiana and Pennsylvania) and all apparently linked to animal exposure, which makes the Iowa cases unique. All but one case has been in children under 10 years old, suggesting prior year exposure to H3N2 might be protective. Perhaps it's ironic that this novel swine strain was first transmitted from human-to-human right here in pig country.

Sources: Des Moines Register 11/22/2011 and Winnipeg Free Press 11/22/2011

Addendum: Iowa just added 2,300 jobs, which I think is about double our human population. I think two ~~job seekers~~ family members (update: actually just in for Thanksgiving) from other states even moved in with Dan this past weekend. Getting crowded here, which might be increasing the flu transmission.

Actual update on the virus: "In these ten most recently reported cases, the virus has been a swine H3N2 virus with the M segment gene borrowed from the 2009 H1N1 virus. Essentially a hybrid – a new reassortant virus - that until this summer had not been seen before." source: Avian Flu Diary

More bad news from pig country

2011-11-22T12:26:00.002-05:00

It is kinda funny moving back to the Midwest after spending almost 20 years on the east coast. To be specific, I grew up in the East North Central region (Great Lakes States) and now find myself in the West North Central (Great Plains States); never mind that Iowa isn't actually in the Great Plains. People are always asking why I would move back or what's it like there in flyover country or the heartland or Middle America - I just smile and say that "all the women are strong, all the men are good looking and all the children are above average." Most of the over-stressed, over-crowded coastal folk have at least heard of Garrison Keillor, so that usually changes the conversation...

The Atlanta Braves' new mascot?

OK, so Maryn McKenna has a nice post over on her Wired Superbug blog discussing two studies looking at MRSA in US retail meats. She first reviews a study by Blake Hanson in Tara Smith's U. Iowa lab that found MRSA in retail pork including spa type t034 (ST398).

The second paper from University of Maryland College Park included testing of 694 samples of retail ground beef, ground pork and ground turkey in the DC area. The somewhat surprising finding was the 17% of turkey and 17% of pork samples were contaminated with MRSA.

The funny part of McKenna's post was that she said that Tara Smith's work was particularly important because "they probably know ST398 better than any other US team looking at the strain" (OK, that's good) "and unlike the other research groups, they are embedded in pig country." ???

We can all agree that Iowa produces a lot of pork, but what about Virginia which is #4 or #5 in turkey production. I guess, we can refer to people in Alexandria as being from turkey country. Oh, and Georgia is #1 in broiler production, so people from Atlanta are now from chicken country. I guess, this re-transplanted Midwesterner is becoming overly sensitive...

Addendum: Strictly speaking, PIGS countries are Portugal, Italy, Greece and Spain which are in the midst of an economic crisis. Iowa's unemployment rate sits at 6% and is operating in a close to balanced budget.

Dogs on call

2011-11-20T13:20:00.001-05:00

Many hospitals have pet therapy programs. At VCU, the Dogs on Call Program is a part of the Center for Human-Animal Interaction, which conducts research on the therapeutic effects of interacting with animals. Click here to view a video about the program.

Now I'm sure that these programs make some of us in Infection Prevention nervous. But as I have argued many times before, an infection-free hospital stay may not be the be-all and end-all for every patient. Sometimes infection prevention is trumped by other facets of patient care. And this, I think, is one of them.

Weekend Update: Almost Thanksgiving Edition

2011-11-18T18:23:00.002-05:00

Batterio killer al II Policlinico: due bambini fuori pericolo
„Il Secondo Policlinico: Source NapoliToday“

Leggi tutto: http://www.napolitoday.it/cronaca/batterio-II-policlinico-neonati-fuori-pericolo.html
Diventa fan: http://www.facebook.com/NapoliToday

Just some random stuff for your enjoyment while you're running around trying to get everything ready before you (a) are invaded by family/friends or (b) invade family/friends or (c) both.

#1: Recently, there was a serious outbreak of Acinetobacter infections in the neonatal care unit of Batterio killer al II Policlinico: due bambini fuori pericolo
„Secondo Policlinico di Napoli, which resulted in the closure of the unit/department/hospital depending on the report you read. English or Italiano

h/t Maryn McKenna

#2: November 14-20, 2011 is Get Smart About Antibiotics Week. SHEA, APIC and IDSA all support this effort and so do we. See also the CDC Get Smart website.

#3: CDDEP has a new ResistanceMap showing US antibiotic prescriptions per capita at the state level. Each state's use is listed. The worst offender: West Virginia which uses approximately 1.2 antibiotic prescriptions/person. Alaska has the lowest use with about 0.5 prescriptions/person. Where does your state rank? Check out CDDEPs map!

#4: Scientific America has an interesting post by Katherine Harmon reviewing two recent Science papers. There is new evidence as to how S. aureus, E. coli and P. aeruginosa respond to stress and how this new knowledge might be exploited to enhance existing antibiotics. Shatalin et al. Science 18 November 2011: Vol. 334 no. 6058 pp. 986-990 and Nguyen et al. Science pp. 982-986

“

Deus ex machina and antibiotic resistance

2011-11-17T15:29:00.002-05:00

Last night, I watched a movie with my young kids. The "plot" involved friends traveling with one of their moms to Japan and then getting lost. It was a bit scary for my kids. I was even a bit worried, since I had no idea how they would ever be found, but this was a Disney movie, so I knew it had to have a happy ending. Just when it all looked lost, the mom realized she had placed a tracking device under her son's skin when he was a baby and she also happened to have the required GPS tracking device in her purse. Boom! Kids found, all was well. Ridiculous. Sure, my kids were happy, but where is the lesson there?

Flashback to a conversation I had three weeks ago with a visiting professor in general internal medicine. She is a very well-known clinical researcher in oncology, an area that is well-funded unlike antibacterial resistance, and I wondered what she thought of the lack of new antibiotics in the pipeline, the rise of novel resistance mechanisms in Gram-negatives like NDM-1 and how she thought this would impact oncology. Her response? Her jaw dropped. She thought that there was always another antibiotic in the pipeline or in the ID physicians back pocket to pull out and save her patients. It had actually never occurred to her that we have had close to zero new classes of antibiotic in decades. It was like life was a Disney movie and we could just pull a new antibiotic out of the air to save the day. Ridiculous.

But, whose fault is that? I don't think it is the oncologist's fault. Is it the ID physician's fault who always sounds so smart and attempts to prove her usefulness by pretending that a polymixin is a useful new antibiotic! Is it the funding agencies that have ignored bacterial infections since the 1960's and certainly since the 1980's? Is it the pharmaceutical companies that closed most antibacterial drug discovery units or governmental rules (patents) that bias against antibacterial investments? Of course, the answer is all of the above and more. All I can offer is that we have to stop pretending that some magical antibiotic will be discovered. There will be no 10x20 to rescue our patients. I would settle for 2x20 or how about "1 good one by 20".

As ID physicians, I think we need to stop pretending that we have effective antibiotics. We need to be more honest about the hopelessness of the situation. If a well-trained practicing oncologist isn't aware of the problem, we aren't doing our job. When we face facts, we will have a better chance of convincing the public and government to actually invest in infection prevention and antibacterial drug discovery. This isn't some Disney movie.

One patient per room, eh

2011-11-16T21:38:00.005-05:00

The Canadian Standards Association released new guidance for hospital construction today. Consistent with AIA guidance, the standards call for single patient rooms in all new hospital construction and renovation in Canada. As Mike has blogged, somewhere Madame Necker is smiling.

The user experience

2011-11-16T00:37:00.011-05:00

I was going to start this post by explaining how busy I’ve been, why I haven’t posted in a while, blah, blah, blah. Then I realized I would undercut that immediately by revealing that I’ve just finished reading Walter Isaacson’s biography of Steve Jobs. I read it on an iPad, of course, so didn’t realize it was over 600 pages long until I had finished it and saw it on display at a Detroit airport bookstore yesterday.

I highly recommend it. I enjoyed learning more of the story behind the personal computer revolution that still seems so recent to me (I vividly recall using the Commodore 64, and then the Mac, both of which were released while I was in college). But I mostly marveled at the fierce vision (and meanness) of Jobs, and how he was still able to motivate people and channel this vision into so many great products.

Does it contain any lessons for healthcare epidemiologists and infection preventionists? I hesitate now, because I hate facile comparisons of other industries with healthcare delivery (yes, I understand that we can learn lessons from the airline industry or FedEx, but I’ll be more receptive when FedEx starts delivery packages that arrive at their drop-boxes with multiple co-morbidities, or when Delta can fly me from Boston to Moline without a missed connection due to multiple small system failures—explaining why I was browsing Detroit airport bookstores yesterday afternoon). I was taken, though, with Jobs's laser-like focus on “end-to-end integration”, and maintaining control of the entire user experience (hardware, software, and content):

“His quest for perfection led to his compulsion for Apple to have end-to-end control of every product that it made…This ability to integrate hardware and software and content into one unified system enabled him to impose simplicity”

Simplicity means that users can actually enjoy, and benefit from, the products in an easy and intuitive way. While digital enthusiasts and computer geeks might want malleable open systems, most of us just want to be able to download that cool song we heard yesterday onto our music player without using too much profanity in front of our kids.

Meanwhile, the U.S. healthcare system might be the least integrated “system” in the world. Hence the “user experience”, to borrow one of Steve Jobs's favorite phrases, “truly sucks.” Having just navigated an elderly family member’s transition through acute care, assisted living, skilled care, and home again, I can honestly say that having some inside knowledge of the system doesn’t help much—it still sucks. Many patient safety initiatives, including infection prevention initiatives, are akin to software patches, temporary fixes to problems that wouldn’t exist if we had a truly integrated system—integrated not around RVUs, profits or operating margins, but around the patients’ simple goal: to get better, and not to be harmed in the process.

I'm having a (hand-hygiene) moment

2011-11-09T15:35:00.000-05:00

We have been working on a hand hygiene surveillance project here in Iowa City. One of my collaborators, Heather Reisinger, just went through and listed all possible "moments" for hand hygiene listed in the various guidelines, which I've pasted below. Yes, I know there is overlap.

However, I think this list exemplifies why we fail in our infection prevention efforts. How can we take such a simple thing as hand-hygiene and make it this complicated? How can the WHO Guidelines on Hand Hygiene be 270 pages long?!?!?! How can we have directive after directive and keep making it more complicated?

Solution: the Iowa City ONE Moment For Hand Hygiene: After you touch anything

And no, you don't need the before since if you haven't touched anything after you practiced hand hygiene, then there hasn't been a moment for hand hygiene. It is only AFTER you touch something/anything! that you have to practice hand hygiene.

Take off gloves - you touched them, wash your hands!

Did you touch a patient, then use hand rub and then exit the room? Do you need to practice hand hygiene? NO; but did you touch anything on your way out, such as a door handle? If yes - practice hand hygiene!

EOR

16 Moments For Hand Hygiene
___entering patient room
___before touching a patient
___before handling medication
___before clean/antiseptic procedure
___before putting on sterile gloves
___after removing gloves
___after exposure to body fluid
___after visibly dirty/soiled
___moving from a contaminated body site to another body site during the care of the same patient (say that one three times while rubbing your belly and head)
___after touching equipment or patient surroundings
___after touching a patient
___exiting a patient room
___before eating
___after using the restroom
___when preparing food
___after delivering food (if worker touches patient, bed linens, or objects in the room)

20 years ago, Magic Johnson changed the AIDS epidemic

2011-11-09T10:44:00.003-05:00

Twenty years ago, Magic Johnson announced his retirement from the NBA because of HIV infection. I remember that moment well. I was in medical school and we all knew that HIV could infect all people. However, at the time little national attention was given to the broad risks of the disease, since the general public and politicians thought that only homosexuals, Haitians, hemophiliacs and heroin addicts (the 4 H's) could contract the virus.

Magic's honesty and subsequent appointment to the National Commission on AIDS changed the whole discourse. Magic didn't have to do what he did. He didn't have to go public. He could have retired and probably lived his life. He took a risk and it paid off for all those with HIV and AIDS. Back then, we all thought this was a death sentence for Magic, like it was for so many before him. Magic's role in changing the conversation probably saved his life and certainly saved many other lives. Thanks Magic.

Personal note: My med-school friend's (Laura Jana) mother, Dr. June Osborn, was the chair of the National Commission on AIDS and played a significant role in getting Magic appointed to Commission and assisted Magic as he framed his message. At the time she said "there is no question in my mind that Magic Johnson has achieved a breakthrough that will result in a fundamental sea change. I have been frantic to get the message across to children and youth, and I know damn well that I can't do it. He can." June has been a wonderful mentor to me over the years and I'm proud to know someone, such as June, who has made such an important public health contribution.

There must be a pony in here somewhere...

2011-11-07T00:13:00.006-05:00

Before mandatory reporting and pay-for-performance, and before zero became the only acceptable infection rate, it was OK to have somewhat subjective, imperfect definitions for healthcare associated infections. No longer!

Never fear…HICPAC has working groups now grappling with three different definitions: for CLABSI, VAP and SSI (full disclosure: I’m a member of these working groups). Here are just a few desired attributes of any newly-modified HAI definition:

Must have excellent performance characteristics (most importantly, nearly 100% specificity) when compared with gold standards (note: gold standards do not yet exist).
Must consist of only objective measures that can be collected by all NHSN participating hospitals, and that are amenable to electronic reporting and easy validation.
Must demonstrate excellent concordance with clinical definitions of infection, so as not to lose credibility with frontline clinicians (note: because of the subjectivity of clinical definitions, this attribute is not consistent with the attribute above).
Must not be subject to “gaming”, even by the most creative hospitals (note: even supposedly “objective” measures, like culture and antibiotic use data, are subject to practice changes in response to pressure to reduce HAI rates).
Must not result in public or political perception that modifications were made in an attempt to lower HAI rates (i.e. “define our way to zero”).

So, keeping these in mind, feel free to submit any suggested changes to current definitions, in the comments section!

The Affect Heuristic

2011-11-04T12:45:00.001-04:00

Source: XKCD.com

We've discussed conflicts of interest and bias frequently, particularly in regards to guidelines. Bob Centor has a nice post today that discusses the affect heuristic and how it might impact clinical guidelines.

The affect heuristic suggests that a good feeling or emotion towards a situation (i.e., positive affect) would result in a person having a lower risk perception and higher benefit perception than supported by an unbiased look at the data. I think this is closely related to confirmation bias, which we have written about frequently, as well.

His recommendation for selection of guideline panels - choose strong methodologists who are non-experts - is one worth pondering.

Disgust and Infection Prevention

2011-11-02T12:36:00.000-04:00

That's disgusting! (source: wikipedia)

Just came across this great article in the journal Philosophical Transactions for the Royal Society B, titled "Why Disgust Matters." In the paper Valerie Curtis of the London School of Hygiene and Tropical Medicine argues that the human feeling of "disgust" evolved to motivate infectious disease avoidance. She suggests that a better understanding of disgust could be harnessed to combat the behavioural causes of infectious and chronic disease such as diarrheal disease, influenza and even smoking.

You could imagine that more knowledge around "disgust" or what motivates good behavior (covering your face when you sneeze or washing your hands) could greatly improve infection prevention in hospitals.

Curtis V, Phil. Trans. R. Soc. B 12 December 2011 vol. 366 no. 1583 3478-3490 (abstract) (full text)

Related BBC Article by Health Reporter Philippa Roxby

Conflicting Results in Clinical Trials: the APC Example

2011-11-01T13:20:00.000-04:00

Dan posted last week on activated protein C (Xigris) being withdrawn from the market. David Rind (Evidence in Medicine blog) has posted his thoughts on what might have been behind the initial positive study in 2001 and subsequent negative studies. It is worth a read.

David Rind: APC and Conflicting Trials (10/29/2011)

Odds and ends

2011-11-01T07:39:00.000-04:00

Here are a few odds and ends that I've been mulling over--some related to infection prevention, some tangentially related, and some, well not at all.

A new paper in the International Journal of Obesity looks to see whether response to influenza vaccine is impacted by obesity. This is important since during the H1N1 pandemic obesity was found to be a risk factor for morbidity and mortality. Interestingly, in this study of nearly 500 participants the investigators found that antibody production is not affected by BMI, but as BMI increases there is a significant decrease in antibody detected at 12 months. The implications of this paper could be huge given the increasing prevalence of obesity in the US.
I just read Steven Berk's recently published book, Anatomy of a Kidnapping, on a quick trip to Vermont. Berk is an infectious diseases physician and medical school dean, who was kidnapped at gunpoint from his home in 2005. He writes that equanimity helped him to stay cool through the entire ordeal. Though this may have saved his life, I think it robbed some of the emotion from his prose, and I was left with little connection to what should have been a very compelling story. And if I were not on a plane without anything else to read, I would have closed the book for sure when he articulates his view that individuals should be allowed to purchase and own assault weapons.
Coldplay's new album, Mylo Xyloto, is simply amazing. I can't quit listening to it. It's already setting records for the rate (there's a tie to epidemiology!) of digital downloads it's receiving.
Dick Wenzel, the most famous hospital epidemiologist since Semmelweis, has in his "retirement" published a novel and danced the tango for charity. This week he will debut in VCU's production of the musical Grease. He plays the DJ, Vince Fontaine. He still has a day job, too--this week he's attending on the Transplant ID Service.

Happy Halloween!

2011-10-31T17:12:00.000-04:00


Maggie and Alicia

Nothing better than infection prevention related Halloween costumes. I'm still trying to imagine Mike dressed as a flu vaccine, but its a bit difficult. Anyway, here in Iowa City Maggie dressed as a collection of hospital pathogens clinging to Alicia, a contaminated textile. Good times.

Science Friday: Influenza Vaccine Debate

2011-10-30T02:38:00.000-04:00

Mike Osterholm, PhD MPH

Earlier this week, Mike posted his thoughts on the recent Lancet ID review of influenza vaccine efficacy. This week's Science Friday featured a "debate" between Mike Osterholm, one of the authors, and Bill Schaffner. The discussion covers several important topics including the utility of influenza vaccine in seniors.

Click here to listen to the mp3 audio (full hour, but the vaccine discussion is first up)

Source: Science Friday (NPR, Talk of the Nation)

Needle-free flu vaccine? Not so fast!

2011-10-27T15:50:00.000-04:00

On second thought. Maybe the hypospray did hurt?

Bummer. We were getting so close to the Star Trek reality we always dreamed about. We can now talk to our communicator-like, Siri-enabled iPhones and until this week, we could get a flu vaccine using a hypospray-like needle-less jet injector. Unfortunately, for your deltoids, FDA now recommends against the use of the intramuscular-labeled vaccine using jet injectors. Only one vaccine, the MMR, is approved for use with the jet injector and the FDA hasn't received the safety and effectiveness data to approve other vaccines using this technology.

Note: This does not apply to the intradermal vaccine, which is supplied in its own pre-filled syringe.

Source: FDA Updated Communication on Use of Jet Injectors 10/26/2011

It's a vaccine, not a miracle

2011-10-27T09:03:00.000-04:00

There apparently was a recent rumor causing quite a stir in some segments of the infectious diseases community that a paper was about to be published that would show that influenza vaccine doesn't work. Well, the paper was published yeaterday and the results don't quite match the rumor. Osterholm and colleagues have published a systematic review and meta-analysis on the efficacy and effectiveness of influenza vaccine in Lancet Infectious Diseases. The major finding was that the pooled efficacy of the vaccine is 59%. This is somewhat lower than that found by the Cochrane group (73% in years when the vaccine and circulating strains were well matched); however, there were some differences in methodology that are well outlined in an editorial that accompanies the paper.

Shocking? I don't think so. I have never thought that influenza vaccine was a great vaccine. It's a good vaccine; certainly good enough to widely recommend its use. But clearly not so good as to fire healthcare workers who refuse to take it.

Two years ago I blogged about the interview in the Atlantic with Tom Jefferson, the head of the Cochrane influenza group. Here's the money quote from that interview:

"For a vaccine to reduce mortality by 50 percent and up to 90 percent in some studies means it has to prevent deaths not just from influenza, but also from falls, fires, heart disease, strokes, and car accidents. That's not a vaccine, that's a miracle."

Headline of the day

2011-10-26T11:05:00.003-04:00

This is my favorite headline about the demise of drotrecogin alpha (a.k.a. activated protein C, Xigris), which was withdrawn from the market yesterday after the PROWESS-SHOCK study results revealed it to be no better than placebo in the treatment of severe sepsis. The headline, of course, implies that Xigris once was effective, it just isn’t any more…and from the quotes in this story, it appears that Lilly is arguing that improvements in sepsis management have now made it impossible to detect the incremental benefit that Xigris provided (you know, back when we were super-terrible at treating sepsis).

Fair enough, but that explanation ignores the controversial history of this drug and the role of Eli Lilly in the surviving sepsis campaign. It also ignores one of the most important lessons we should learn from this debacle: the perils of the subgroup analysis. Eli, our in-house methodologist, may wish to chime in, but you can start here with a nice review that points out why subgroup analyses of clinical trials should be treated with extreme caution, and used only to generate hypotheses, not for clinical decision making (or drug approval!).

1 week to 7 billion

2011-10-25T10:45:00.000-04:00

(AP Photo/Pavel Rahman): Bangladesh

7 billion people. Seven billion. Unimaginable. The UN Population Fund estimates by October 31, 2011, the world's population will be 7 billion. Only 200 years ago, there were 1 billion people on the planet and it took 150 years to get to 3 billion. The UN projects that it could grow to 15 billion by the year 2100. I wonder if it will even be possible to control the emergence of resistant pathogens like NDM-1 if we don't first address the population crisis.

Atlantic Monthly has a wonderful series of photographs that highlight the population explosion and the secondary environmental impact.

My favorite comment below the photo series is "7 bil peeps can fit in an area 34x34 miles. Shoulder to shoulder back to front." I don't know if this is true, but perhaps they can test it out on MythBusters.

h/t JJ Furuno

Encouraging antibiotic development: a grassroots effort

2011-10-25T06:43:00.001-04:00

Dear Readers,

I have just received this call to action from Dr. Timothy Walsh, Professor at Cardiff University, who I mentioned last week in regards to the NDM-1 crisis in India. Below is an online petition from the British Society for Antimicrobial Chemotherapy (BSAC), that I would urge you to sign. The petition will be presented to 10 Downing street (British Government) on the 9th of November followed by a garden reception to further articulate the crisis we currently face.

Antibiotic Action

Securing the future of antibiotic development …. determined to make a difference

www.antibiotic-action.com

New antibiotics are urgently needed for use now and in the future

No antibiotics – no chemotherapy | No antibiotics – no transplant surgery | No antibiotics – no hip/knee replacements | No antibiotics – no treatment for infectious diseases| No antibiotics – no heart surgery | No antibiotics – no cystic fibrosis treatment | No antibiotics – no kidney transplants

NO ANTIBIOTICS – NO CURE – NO CHANCE

The simple truth

Please join this global initiative - sign the petition on the website above.

Thank you.

Another nail in vanco's coffin

2011-10-24T07:41:00.000-04:00

Photo: Old-Pictures.com

Eli's group, with Marin Schweizer as first author, has just published a retrospective cohort study in BMC Infectious Diseases (full text here) that addresses an important and relatively common clinical question: should we treat methicillin-susceptible Staph aureus bloodstream infections with vancomycin? Most infectious diseases experts agree that cefazolin or nafcillin are better for MSSA because these drugs provide better bactericidal activity than vancomycin. Nonetheless, vancomycin's pharmacokinetics usually allows for more convenient dosing. As more patients are being treated at home with IV antibiotics, drugs that require every four hour dosing (e.g., nafcillin) are much more difficult to use unless the patient is willing to use a small programmable pump that must be carried at all times. Vanco may be even more attractive in patients with renal failure since dosing becomes very infrequent. On the other hand, I am finding it harder to maintain therapeutic trough levels with vancomycin. In young patients with high creatinine clearances, I sometimes find that even every 8 hour dosing results in trough levels that are too low. Supratherapeutic troughs occur when renal dysfunction develops, which is not uncommon in acutely ill hospitalized patients. And it seems that as we push the levels higher we are seeing more renal dysfunction. So vancomycin drives me a little crazy.

But what did Eli find? In his cohort of 267 patients with MSSA bacteremia, those that were treated with cefazolin or nafcillin (including those who also received vancomycin) were nearly 80% less likely to die than those who received only vancomycin for the duration of their treatment. What about the common clinical scenario where vancomycin is started empirically then changed to cefazolin or nafcillin once MSSA has been identified? Those that were switched from vancomycin were 69% less likely to die than those who continued on vanco. Bottom line: think twice before using vancomycin solely on the basis of convenience.

Predicting the future

2011-10-23T17:47:00.000-04:00

There's a perspective in this month's Emerging Infectious Diseases on carbapenemase-producing Enterobacteriaceae (full text here). For the most part, it's a well written piece that focuses on the geographic spread of these organisms. Near the end, however, the authors make a pitch for active surveillance:

The prevention of spread of carbapenemase producers relies on early detection of carriers. Patients who undergo screening should include patients who were hospitalized while abroad and then transferred to another country, and patients at risk (e.g., patients in intensive care units, transplant patients, immunocompromised patients). Screened patients should be kept in strict isolation before obtaining results of the screening (at least 24–48 hours). Because the reservoir of carbapenemase producers remains the intestinal flora, fecal and rectal swab specimens are adequate for performing this screening.

Yikes! If I followed their advice my hospital would probably be doing a few hundred tests per week. I'll leave the thorny problem of what test to do to Dan, our blog's microbiologist. But more active surveillance means more contact precautions. And we love contact precautions!

Photo: Managed Care Matters

So let me look into my crystal ball and predict the future for our readers:

A diagnostic testing company will develop a rapid test for the detection of these organisms
The diagnostic testing company will become a strategic partner to A Group that Represents Infection Preventionists (AGRIP)
AGRIP will survey all of its members on whether they have ever seen such organisms in their hospitals
A paper will be published along with a press release revealing the shocking news from the survey that these organisms are much more prevalent than anyone ever imagined
The strategic partner (bless their heart!) will help AGRIP educate the infection control community and the public on the dangers of this horrible organism
I'm a little fuzzy on this prediction, but there may be a second survey
States will pass laws requiring testing of patients admitted to hospitals to protect their citizens from the horrible organism
The strategic partner will hire a new vice president and all will live happily ever after

I will now put the crystal ball away, return to my regular life as a horizontalist, and simply scream, WASH YOUR HANDS, PEOPLE. WASH YOUR HANDS!!!

Don't poo-poo it!

2011-10-23T10:00:00.000-04:00

Photo: People's Pharmacy

There's a new systematic review in Clinical Infectious Diseases on intestinal microbiota transplantation (AKA stool or fecal transplantation) for Clostridium difficile infection. In scouring the literature, the authors found reports of 317 patients who had received this treatment with an overall success rate of 92% and no attributable adverse effects.

Stool transplantation was first performed in a human in 1958; however, veterinarians have used this treatment for hundreds of years in treating horses with chronic diarrhea. The vets call it "transfaunation," which I think sounds better than what we call it.

I first became interested in this treatment when I began getting patients referred to me who had had numerous episodes of C. difficile infection over long periods of time despite treatment with every known pharmacologic intervention. I've now done 10 or so transplant procedures. Unfortunately, the systematic review does not describe the duration of diarrhea that patients endured prior to transplantation, but in my experience, patients have often had diarrhea for months. A few months ago, I successfully transplanted a patient who had diarrhea for six years every time oral vancomycin was discontinued. And what's most amazing about this treatment is the rapidity of its effect--most patients have resolution of symptoms within 24 hours. One patient called me to say that she screamed with delight on having her first normal bowel movement in 6 months just 1 day after her transplant.

When I explain the procedure to patients, I always give them the option of doing the procedure themselves at home (a DIY paper was published last year), but when I get to the part about the blender, the patient invariably cuts me off with a big "NO!".

There are still skeptics, however. The purists say they would never perform such a procedure without results of a randomized controlled trial reporting effectiveness. Of course, publication bias may be at play here, making the procedure appear more effective than it truly is. But I think that being a good doctor sometimes forces you to confront the limits of evidence, step outside of your comfort zone, and try a therapy that's cheap (particularly when you consider that a 2-week course of oral vancomycin costs about $2000), probably effective, and safe when appropriate precautions are taken. And there's an argument to be made that when a treatment has a dramatic effect (a rapid response on a stable background), the risk of bias accounting for that effect is very low.

For those of you who want to read more, there's an excellent, recently published, perspective piece in Clinical Gastroenterology and Hepatology that nicely reviews the rationale and methods for performing the procedure.

Some good news for a change...

2011-10-22T13:53:00.000-04:00

Photo: Robert JR Graham.com

This week CDC announced progress made on reducing healthcare associated infections. Analyzing 2010 data from the National Healthcare Safety Network, CDC found:

A 33% reduction in central line-associated bloodstream infections (35% reduction in ICU patients and a 26% reduction in non-ICU patients).
A 7% reduction in catheter-associated urinary tract infections throughout hospitals
A 10% reduction in surgical site infections
An 18% reduction in the number of people developing health care-associated invasive MRSA infections

"Young" doctors and vaccines

2011-10-21T14:09:00.000-04:00

Vaccines these days can't catch a break. Back in the day when people were dying from polio and measles, everyone (including physicians) could see the benefits of vaccines first hand. Now, with the success of vaccines in the bag, the ground has shifted against vaccines from "seeing is believing" to "what have you done for me lately."

There is an abstract at IDSA that reports that young physicians are less supportive of vaccines. Sara Kliff at the Washington Post reports that Michelle Mergler (Emory) and Saad B. Omer (Johns Hopkins) found that recent medical school graduates were “more likely to believe immunizations do more harm than good" and were 15 percent less likely to believe vaccines work. Bummer.

see also: Shari Roan, LA Times 10/20/2011

100 to 200 Million with NDM-1 in India

2011-10-21T13:31:00.002-04:00

Dr. Timothy Walsh, Cardiff

We've continued to follow the emergence of NDM-1 around the globe. A recent interview in the Times of India that Tim Walsh gave was an interesting read and very concerning. Walsh is the lead author of the recent Lancet ID paper that Dan commented on earlier this year which reported NDM-1 bacteria in 4% of drinking-water samples and 30% of waste-water samples in New Delhi.

Most concerning was his suggestion "that the carriage rate of NDM-1 in India is between 100 and 200 million" people. Crazy. The interview is a great read since he pulls no punches.

Source: Times of India, October 9, 2011

The last IDSA...for a while?

2011-10-20T00:36:00.002-04:00

Everyone around here seems to be off to IDSA. This is the last IDSA before a whole gamish of societies (IDSA+SHEA+HIVMA+PIDS) becomes IDWeek. In honor of all of my ID colleagues headed to Boston, I offer the following cartoon. I think ID physicians are doctors among doctors, we just aren't reimbursed as such. Have fun and look both ways.

Pee first, then think!

2011-10-17T19:57:00.000-04:00

Photo: Run On!

At the gym today I was reading the Chronicle of Higher Education while riding the bike and came across an article on the Ig Nobel awards. These awards are for research papers that first make people laugh, then make them think. One of the winners in the Medicine category went to the investigators who did a study published in Neurourology and Urodynamics on the effect of acute increase in urge to void on cognitive function (full text here). The study subjects drank 250 mL of water every 15 minutes until they could no longer inhibit voiding. Cognitive tests were performed hourly from baseline through extreme urge to void and then postmicturition. The investigators found that the extreme urge to void state was associated with significant declines in cognitive function that reversed after voiding.

Very interesting study, isn't it? So it got me to wonder whether Tom Talbot had to pee really badly when he drafted the SHEA position paper on flu vaccine for healthcare workers. Fess up, Tom!

Disclaimer: Tom's a great epidemiologist and regular reader of our blog, so this is all in fun.

You say meticillin and I say methicillin

2011-10-17T14:47:00.002-04:00

Although not the "highest level" of evidence in the scientific literature, I often find the personal reflections of senior scientists very entertaining and often useful. One of my favorite in the genre was Robert Wise's 1989 reflections on nosocomial S. aureus published in RID/CID. Barry Cookson has a similar reflection in the October 8 Lancet titled "Five decades of MRSA: controversy and uncertainty continues."

Barry labels each decade of MRSA research and control with interesting titles. For example, the 1970s were the "decade of complacency" while the 1990's were the "decade of dawning realization." He sprinkles in personal anecdotes, etc and echoing what Dan and I wrote in JAMA last year, he ends with a spot-on conclusion:

"However, my major concern is that, with the downturn in the economies around the world and reductions in MRSA, there will be a tremendous temptation to reduce the funding of prevention and control measures. It is vital that policy makers and governments realise that they must continue to spend money to save money. MRSA and other hospital infection pathogens will continue to pose threats to patient safety in the foreseeable future. One thing is certain: the response to these challenges will determine the next decade of research and reaction to MRSA."

Hear hear!

Source: Cookson B, Lancet 2011 (378): 1291-2.

Abstract of the Year?

2011-10-16T10:41:00.000-04:00

I know this isn't HAI related, but it did have me dreaming up abstracts for some of my projects...

This is a real paper that can be found here.

h/t JJ Furuno and the incidental economist

Factoid of the day

2011-10-15T20:10:00.000-04:00

1 in 6 cell phones is contaminated with fecal bacteria (read about it here).

Photo: Wired

Climate change and hospital pathogens

2011-10-14T08:45:00.000-04:00

Do hospital pathogens like living in a Greenhouse?

Nothing should dare threaten your coffee. So when Starbucks announced today that global climate change is threatening coffee supplies, you knew it would get media attention. What's a journalist without their coffee and cigarettes? (aaaack) What about hospital pathogens? Could climate change impact hospital infection rates. We thought it might. (Note: by we, I mean my colleague from Maryland Judy Johnson - She's now in Gainesville).

Back in 2006, Judy and I were sitting on a park bench (it was a nice day) discussing the upcoming ICAAC abstract deadline and pondering what we should submit, when she suggested we look for seasonal variation in Gram-negative pathogens. Judy mentioned some data suggesting Gram-negative infections were more common in tropical countries and we also discussed the high incidence of Acinetobacter infections in troops returning from Iraq. Sure, we also knew that others had noticed summer peaks in certain pathogens, but the prior research didn't control for meteorologic factors and also combined summer data from across the entire US (hint: Maine ≠ Texas). Thus, we felt there was room for further exploration.

In our initial analysis, published in ICHE (2008), we reported that summer season (vs. winter) was associated with 28% more P. aeruginosa, 46% more E. cloacae, 12% more E. coli and 21% more A. baumannii clinical cultures over 8 years. Importantly, we found that for each 10°F increase in temp, there was a 17% increase in the monthly rates of infection caused by P. aeruginosa and also A. baumanii. Of course, this was a single center study, so we needed more proof.

Mike Eber and our group have just published a follow-up study in PLoS One looking at BSI data from 132 hospitals over 8 years. Using 211,697 inpatient blood isolates, we again found that Gram-negative organisms were more frequent in summer months ranging from 12.2% higher rates for E. coli to 51.8% higher for Acinetobacter spp. And more interestingly, we reported that independent of season, monthly humidity, monthly precipitation, and long-term trends, each 10°F rise in mean monthly temperature was associated with higher Gram-negative bacterial BSI frequencies ranging between 3.5% for E. coli to 10.8% for Acinetobacter spp. Thus, warm temps = more Gram-negative bacteremias; that is, even a warm winter is a bad thing. Lots more work to do to figure out why this might be, but I think it's an interesting first (or second) step. Cheers.

Note: Special thanks to Ramanan Laxminarayan and Extending the Cure for supporting this project.

Good riddance!

2011-10-13T16:00:00.002-04:00

I’m so happy to see this flawed performance measure dropped. I think I’ll take a 5 minute break to write a blog post, then another 5 minute break to stare out the window and marvel that a measure with such toxic unintended consequences was actually abandoned!

h/t to Edward Goodman, via a post on the EIN this morning.

Chart of the day

2011-10-13T05:47:00.000-04:00

The figure below comes from a new study in PLoS Medicine using data from the European Antimicrobial Resistance Surveillance System (EARSS) to model expected trends in bloodstream infections due to MRSA and 3rd generation cephalosporin resistant E. coli (G3CREC) in Europe. Click here for the free full text of the paper.

Bathrooms and Infections

2011-10-11T12:15:00.001-04:00

Maryn Mckenna (Colin Purrington started the meme) has an nice post on bathroom design and infection risk on her SuperBug blog. One thing I was not aware of was that hot air hand dryers "pull air from the bathroom floor, not from the outside, so all they’re doing is shooting a blast of hot bacteria full force onto your hands. One study showed that using electric dryers increased bacteria levels on hands by 162 percent.” It's all pretty scary. I think alcohol hand rub is the answer. I like how O'Hare airport in Chicago has alcohol hand rub dispensers just outside each bathroom.

Oh, if you like the signs on the hot air dryer and door, just download Purrington's door signage and hand dryer signage files (PDFs) and print onto 4 x 6″ 3M removable adhesive labels (#6200). Thanks Colin and Maryn!

Flu shot: Just take it on faith

2011-10-08T13:06:00.000-04:00

Photo: Media dis&dat

The Journal of Hospital Infection has just published a systematic review on the effectiveness of seasonal influenza vaccination in healthcare workers. Here's the money quote from the abstract:

No evidence can be found of influenza vaccinations significantly reducing the incidence of influenza, number of ILI (influenza like illness) episodes, days with ILI symptoms, or amount of sick leave taken among vaccinated HCWs.

It's important to remember, however, that absence of evidence for the vaccine's effect, is NOT evidence of absence of an effect. I'm getting my flu shot this week, but I'm taking it on faith.

WHAP VAP in 8 easy steps

2011-10-06T00:00:00.001-04:00

We’ve covered this before…..how difficult it is to define VAP, how easy it is to reduce rates without improving outcomes, etc. Well, now Michael Klompas has published a handy guide entitled, “Eight initiatives that misleadingly lower VAP rates”. You’ll need a subscription to AJIC to read it, but it is a compelling document. I’m disappointed that he couldn’t come up with just 2 more, to make it a “top 10” list. How about adding: “lie”, and “make 'infinity' the new denominator”. That was easy!

Hand hygiene in the emergency department

2011-10-05T10:39:00.003-04:00

ICHE has an interesting paper up on hand hygiene (HH) in the Brigham and Women’s emergency department. As part of a QI program, the ED deployed 5 trained observers and an infection preventionist to performing HH audits for 16 months. Impressively, they covered all days of the week, and all shifts (much of our data on HH comes from weekday first-shift observations, which may differ from what one might find on weekends or at night). The overall adherence was good, at ~90% (the observers were known to the ED personnel, but this is still an excellent rate of HH). The most notable findings included (a) physicians had slightly higher adherence than nurses, which runs counter to the conventional wisdom, (b) transport personnel had the lowest adherence (<70%), and (c) hallway location (which by definition translates to an overcrowded ED) was associated with lower adherence (82%, compared with 91% in a private room).

Because I’m always on the lookout for more reasons to despise contact precautions, I immediately seized on this last finding. As Mike and his colleagues pointed out in a study published in March of this year, difficulty in finding beds for patients requiring contact precautions is one factor that exacerbates ED overcrowding. At Mike’s hospital, patients who required contact precautions waited in the ED for an hour longer than those who did not. Active detection and isolation programs make this problem even worse, as pointed out in this Irish study—patients colonized or infected with MRSA waited 2.5 hours longer in the ED than did those who were not identified as being at high-risk for MRSA.

In other words, not only does ED overcrowding lead to poorer HH and increased risk of pathogen transmission, but the patient population in many EDs may be “enriched” with MDRO carriers (who stay in EDs longer while awaiting a bed)!

"New hospital will be superbug free"

2011-10-04T07:30:00.000-04:00

Rendering of the new University Hospital of North Staffordshire
From: NHS Stoke on Trent

The title of this post is actually the title of a newspaper article that appeared today in the UK. Hospital officials claim that in this new building "MRSA will be eradicated," and even though patients may bring in C. difficile from home, "its chances of spreading once in wards and departments will be zero." The article extols the virtues of a new hospital with more private rooms, and the CEO of the hospital proclaimed "we will have the capability to eradicate hospital associated infections."

Really?

These comments are either incredibly naive, blatantly dishonest, or APIC-speak (i.e., we know this actually can't be achieved, but it's an aspirational goal). Regardless, it's another example of getting-to-zero run amok.

Your dirty laundry

2011-10-03T17:07:00.000-04:00

Photo: Mary Ann's Cupboards

There's a new paper in Infection Control and Hospital Epidemiology that includes a series of experiments designed to evaluate the effectiveness of laundering scrubs in your home washing machine. This is important since most healthcare workers who do not work in the operating room launder their own scrubs at home, and some hospitals even have OR staff wash their scrubs at home as a cost-savings measure. The major difference between home and hospital laundering is water temperature--hospital laundries typically use water temperatures of 160°F, whereas home washing machines are generally set to deliver water temperatures at 60-80°F (cold), 90-110°F (warm), or >130°F (hot).

Key findings were:

Hot water (140°F) with or without detergent was highly effective in killing MRSA and Acinetobacter.
Warm water (104°) with detergent was highly effective in killing MRSA and Acinetobacter. Without detergent, warm water was still highly effective against MRSA, but only moderately so against Acinetobacter.
When clothes are washed with warm water but no detergent, they become contaminated with gram-negative organisms (Klebsiella, Enterobacter, Serratia) from the washing machine's biofilm, though washed clothes are largely free of gram-positive skin flora.
When fabric swatches that were inoculated with Acinetobacter were ironed (on the iron's highest setting) with a contact time of at least 7 seconds, the organisms were killed.

So warm or hot water with detergent is your best bet (though I have to wonder who washes their clothes without detergent?). I do iron my scrubs, though many people don't, but I'm sure that my ironing contact time is less than 7 seconds, and some scrub fabrics can't tolerate the iron's highest setting.

Cuyahoga Moment - and the End of Antibiotics

2011-09-27T13:30:00.002-04:00

Cleveland, even now I can remember

'Cause the Cuyahoga River

Goes smokin' through my dreams

-Randy Newman, "Burn On"

Dan's ICAAC-"Destroyer of Bundles" post last week was surprising for several reasons: (1) because my talk was an overview of which components of the bundles were most effective and never suggested bundles didn't work, i.e. we don't know exactly which components contribute most to the success of bundles and (2) because he mentioned ye olde burning river, the Cuyahoga.

We actually owe a lot to the Cuyahoga River. The Cuyahoga caught fire numerous times dating back to 1868, but it was the 1969 fire that caught the public imagination through a Time Magazine article that described the river as one that oozes rather than flows. It was this 1969 fire and the attention associated with it that led to the creation of the EPA and the Clean Water Act. In fact, Paul Krugman, recently suggested that the Cuyahoga fire was the start of Environmentalism in this country. Because of the fire, the Cuyahoga and Lake Erie and numerous other bodies of water in the US have sprung back to life. Thank you Cuyahoga and thank you Cleveland.

So, why am I writing about the Cuyahoga in an HAI blog? Because I've been waiting for years for our "Cuyahoga Moment" that will start the process of the US taking antibiotic resistant organisms and antibiotic drug discovery seriously. Perhaps, someday we might even see an agency created that would be charged with guiding the creation and stewardship of antibiotics. How 'bout the Agency for Antibiotic Protection? I first thought perhaps VRE or MRSA, then VRSA would have gotten serious attention and I even thought the recent run of KPC and NDM-1 would have done the trick. No such luck. We are still left with an underfunded CDC that can barely afford to do simple quasi-experimental studies, a pharmaceutical industry that has closed down most antibiotic discovery efforts and an NIH that focuses almost entirely on non-bacterial pathogens. I probably shouldn't even mention non-human use of antimicrobials. Sadly, I suspect it will take a shuttering of a transplant program or a whole hospital or something far far worse to alert the public and the Government. What do you think it will take?

Burn on, big river, burn on...

On the physical examination

2011-09-27T06:09:00.000-04:00

Here's a TED talk (or perhaps more appropriately an anti-TED talk given the subject matter) by Abraham Verghese that ends with the audience awarding him a standing ovation.

The dirty curtain story

2011-09-25T23:14:00.006-04:00

We recently began a study of microbial contamination of hospital privacy curtains (a study funded by one of several manufacturers of an antimicrobial fabric). The comparative study is ongoing, but the “baseline” sampling confirmed what Curtis Donskey’s group has already described: hospital privacy curtains are often contaminated with bacterial pathogens (the main additional findings from our study have to do with how quickly the curtains become contaminated (spoiler alert: very quickly), and how some organisms persist on curtains over time). Figuring the results might generate some interest among a few attendees, and perhaps spark some useful discussion of this and other environmental infection control issues, we decided to submit the baseline data to ICAAC. We had yet to learn this valuable lesson:

Never underestimate the media’s fascination with the presence of bacteria on inanimate objects.

Stethoscopes, ties, white coats, rings, cell phones, you name it. If you want media attention, grab some swabs, head up to your nearest patient care unit, and find some new object to culture! By Friday after ICAAC, the story had been picked up by CBS News, Reuters Health, Fox News, etc., etc. (I can’t bother with all the links, just type “privacy curtain” into Google News). It has turned into a minor annoyance, as we seek to put these findings into perspective in our own hospital, and navigate the obvious conflict-of-interest inherent in managing the findings of a study sponsored by an industry that has a vested interest in the outcome.

So, what are the implications of this study? Most importantly, consider privacy curtains to be like any other high-touch surface in the patient environment, and perform hand hygiene after contact with the curtain. This can be a real challenge in an ICU environment that doesn’t have private rooms, so other approaches seem wise as well: more frequent cleaning/changing of curtains (in most hospitals they are changed only when visibly soiled), use of a “pull rod” or other plastic object to allow one to pull the curtain around without touching the fabric (the plastic surface can be more easily disinfected), or use of other barriers (e.g. glass doors that turn opaque). There’s a burgeoning interest in antimicrobial fabrics (not just for this purpose, but for healthcare worker clothing, etc.), and these may also play a role. Finally, Mike’s prior posts on single patient rooms are pertinent—well-designed private rooms can obviate the need for frequent use of privacy curtains.