And what about antimicrobial scrubs?

Ascot: a neckband with wide pointed wings, traditionally made of pale grey patterned silk

The role that environmental transmission plays in the spread of important pathogens is increasingly recognized. One of the major mechanisms by which pathogens are thought to spread is via contaminated healthcare worker clothing. A major reason that gowns are included in contact precaution is that they are felt to interrupt the transmission from patient/environment to HCW attire. An old (2010) study that Dan Morgan completed found that gowns became contaminated 11% of the time when caring for patients with MDR-Acinetobacter and 5% of the time when caring for patients with MDR-Pseudomonas. A repeat (2012) study found that gowns became contaminated during 4% of HCW visits caring of MRSA+ patients, 5% for VRE, 2% for MDR-Pseudomonas and 13% for MDR-Aceintobacter.

With so much contamination and a desire to rid the world of unnecessary gown use, investigators have been exploring the benefits of antimicrobial textiles, such as scrubs. If these novel scrubs could reduce contamination, maybe we could drop the dreaded gown and go with universal gloves for contact precautions?

Which brings us to a ASCOT study by Deverick Anderson and colleagues funded by the CDC Prevention Epicenters Program. ASCOT: Antimicrobial Scrub Contamination and Transmission. The investigators examined the benefits of two different antimicrobial scrubs (Scrub 1: silver-alloy and Scrub 2: organosilane-based quaternary ammonium and a hydrophobic fluoroacrylate copolymer emulsion) vs standard poly-cotton surgical scrubs in a 3-arm RCT during 3-consecutive 12-hour ICU nursing shifts. The primary outcome was change in total contamination on the nurses scrubs as sum of CFUs. Of note, all MDRO colonized patients in the study were placed on contact precautions and HCW placed gowns over their scrubs and wore gloves while caring for those patients.

The study collected many cultures: 2919 from the environment and 2185 from the HCW clothing. 41 nurses were randomized but one was excluded for a total of 40 nurses caring for 102 patients during 167 encounters. Their primary finding was the scrub type had no effect on HCW clothing contamination (p=0.70) There is a lot to unpack in this study and it warrants a careful read - a lot of data! but I've included Table 3 below with the contamination before/after each shift. Overall, the median CFU increase was 61.5 (interquartile range [IQR], −3.0 to 191.0) in the control arm, 73.0 (IQR, −107.0 to 194.0) in the Scrub 1 arm, and 54.5 (IQR, −60.0 to 215.0) in the Scrub 2 arm.

There were acquisition events during 39 (33%) of the shifts with 20 (17%) environmental acquisitions and 19 (16%) acquisitions on HCW attire. Looking at the 19 HCW attire acquisition events, 12 (63%) were confirmed: 7 from the patient, 3 from environmental contamination, and 2 from the patient/environment.

Overall, the authors reported that there were no benefits from either antimicrobial scrub. However, there was significant transmission from patient or environment to HCW attire.  Back to the drawing board on antimicrobial scrubs?  Maybe. I would like to see the study repeated in a hospital where contact precautions are not used to see if benefits might exist in settings where gowns are not worn when caring for MDRO+ patients. With this much acquisition of nurses' clothing, it's going to be hard to ditch gowns, unfortunately.

Oh, and I love the ASCOT name. Brilliant.

CDC Prevention Epicenters expanded!

Regular readers know that we often call for increased funding for infection prevention. So naturally we’re very excited that CDC is expanding their Prevention Epicenters program from five centers to eleven. The University of Iowa is honored to be one of the newly added Prevention Epicenters (we’re actually rejoining this program after being a Prevention Epicenter for the first two cycles, from 1997-2005). The principal investigator for the Iowa Prevention Epicenter is fellow blogger Eli Perencevich, with additional project leadership by Loreen Herwaldt, Phil Polgreen, Marin Schweizer, and support and collaboration from many other investigators both at Iowa and at other centers across the country. 

You can read more about the program expansion at CDC's Safe Healthcare blog (post to go up later today), and from the CDC press release. And of course we’ll continue blogging periodically about work funded by this program. All I would add is that this is a good start: if we were to provide funding commensurate to the magnitude of the problem of healthcare associated infections, we’d expand the Prevention Epicenter network another 10-fold or more. To do so would not be a major investment in the context of other funding priorities. For example, the total of $11 million dollars awarded to the six new Epicenters is $3 million dollars less than the annual cost of establishing a redundant Catfish Inspection Office.

Death of the Mid-Career Investigator

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

Go Epicenters!

The CDC just announced ongoing funding of the Prevention Epicenters (PE) program. You can read John Jernigan’s post at Safe Healthcare for the details. We have been involved in this program in the past (the University of Iowa participated during the first two rounds, and both Sloan-Kettering and Maryland were Epicenters while Eli was in those locations). Loreen Herwaldt worked with our Iowa group to put together a great application for this round. Alas, we fell short—but to a group of sites with real depth in the science and practice of healthcare epidemiology.

Collaborating within a multicenter research consortium has its challenges, and progress often seems painfully slow. It’s impressive, then, to look at the body of work that has come out of the PE program, especially given the shoestring budget from which it has been funded. Ten million dollars sounds like an awful lot of money, but spread over 5 centers (each of which represents a healthcare system) and 5 years, minus the institutional overhead, it doesn’t leave much to do studies that might lead to new insights in prevention. Too often this means scaling down prospective interventional trials into less-definitive-but-still-valuable observational studies, simply for want of funds.

Stacked against the morbidity, mortality and cost of health care associated infections, HAI prevention research is massively underfunded. The PE program is a great example, but should be scaled up 10-100 fold.