Dear Stewardship People: Can't We All Just Get Along?

The following post is by Dr. Jasmine Marcelin from University of Nebraska Medical Center.

Teams should work together, not compete

I am an Antimicrobial Stewardship Leader. As the Associate Medical Director of Antimicrobial Stewardship at my institution, I work with another physician (Antimicrobial Stewardship Medical Director) and an ID-trained Antimicrobial Stewardship PharmD. We have a great setup, share audit and feedback responsibilities, and have different interests clinically and for research, which makes it great to divide tasks for initiatives. I focus on outpatient ASP and SSI prophylaxis, PharmD on AU initiatives and cost, and other MD on CDI. We cover for each other, review and co-author each other’s grants, papers and presentations, and present education to various hospital groups together. We work well as a TEAM.

Teams are great things. Nothing meaningful can be accomplished when working alone and in silos. Some ASP teams also include nurses, infection preventionists, advanced practice providers and laboratory personnel, and the specific ASP leadership model will depend on the resources at an individual hospital. Each of these groups bring a very specific and unique skillset to the ASP team. Why is it then, that we seem to find ourselves in the midst of an MD-PharmD power struggle?

In February 2018, the IDSA, SHEA and PIDS released a statement that ID physicians should be leading the way in Antimicrobial Stewardship. This statement shared the unique skillset that ID doctors bring to the ASP table, including years of clinical training in the diagnosis and management of infections. This position paper reads as a statement of support from our societies demonstrating our value to hospital leadership. “Hey C-suite, we have these requirements for ASP, and it says you need a leader that has ID expertise. We literally went to school for ID, and we already work for you, so here are these reasons why you should actually PAY us for what we know how to do well, instead of asking us to do it for free while we are on hospital consults?” The position paper did not say, “ID physicians are better than Pharmacists at ASP”. In fact, the document went on to state, “An ASP should also include at least 1 pharmacist, ideally with subspecialty training in ID. While ID physicians and pharmacists may often have the most central roles in an ASP, all members of the ASP team, including microbiologists and infection preventionists, provide distinct skills of great value.”

Notwithstanding the explicit acknowledgement of the value of the team model of ASP, perhaps the conclusion “ID physicians are well equipped to lead multidisciplinary ASPs given their training, expertise, and experience” offended some of our pharmacist colleagues. The publication was followed by a letter to the editor in May 2018 that stated, “In identifying ID physicians as uniquely qualified for these functions, the paper fails to acknowledge the essential leadership and skill set of ID pharmacists in stewardship”. The letter then concludes, “Best care for patients is achieved through multi-disciplinary stewardship where pharmacist leaders are key to success”. This letter led to a flurry of social media posts misguidedly comparing the “value” of ASP physicians vs pharmacists. A real world study of ID fellow experiences with ASP shared that fellows looked to “pharmacists, not ID physician leaders as primary resources for antibiotic teaching”, and there was a social media frenzy that pharmacists should lead ASP, not ID physicians.

Seriously?

People, this is not a competition! Pharmacists are uniquely equipped to lead ASP because of their special training in the PK/PD of antibiotics, adverse drug effects, drug-drug interactions, and costs. ID physicians are uniquely equipped to lead ASP because of their special training in direct patient care, being boots on the ground as well as eyes in the sky, and can always use the “peer” card when approaching rogue prescribers. The thing is, we are BOTH essential for a successful ASP, and organizations should strive to fund BOTH, because we complement each other. The thing is, we ID physicians have had a long struggle for institutional acknowledgement and respect of our invaluable contribution to patient care. In our fight for recognition, perhaps we have failed to let our pharmacist colleagues know that we appreciate what they do, and that our work is enriched by their contributions. Perhaps we should be intentional to thank our pharmacists for this contribution so that they do not feel we are trying to usurp them and dismiss their value.

Physicians acknowledge and applaud pharmacists’ tireless contribution and value added to the ASP team. We support you in leadership roles. When we say we as physicians are suited to be ASP leaders, it is because we are. It does not diminish your role as co-leaders in a multidisciplinary team; neither does your teaching of antibiotics to ID fellows diminish our role as clinical experts to trainees. Can’t we all just get along? Time to put this superfluous competition to rest and support each other’s value, for the patients’ sake!

Remember me if I forget (to blog)

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

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

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

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

ICD Coding and MDRO - If you don't bill for it, it doesn't exist

Fact 1: Infectious Disease specialists are among lowest paid physicians in the US

Fact 2: Many infectious diseases, including HAI, are absent from ICD billing codes or are poorly coded, and thus the true population health impact of infections, particularly MDROs, is invisible

Hypothesis: If we could improve ICD codes for infectious diseases, ID salaries would increase and the field could be saved from extinction

Many of us on the blog have lamented about the current state of ID with a particular focus on low relative salaries compared to other medical subspecialties and concerns about the annual fellowship match. If we focus on academic ID, the folks who supposedly will train the next generation, we also need to worry about low levels of NIH funding for anything other than HIV research; a trend that is slowly improving. (Fact 1, above)

Our group has looked at the accuracy of ICD billing codes for both HAI and MRSA and the results are not pretty. Michi Goto completed a systematic review of ICD code accuracy for CDI, SSI, VAP/VAE, CLABSI, CAUTI, post-procedure pneumonia and MRSA. He found that apart from CDI and orthopedic SSI, the codes have poor sensitivity and specificity. Marin Schweizer looked at the validity of the V09 code pre-2008 for MRSA and found it to be a very poor at detecting proven incident MRSA infection. (Fact 2, above)

Since many of those studies were completed, there have been new codes added for CLABSI (October 2011), VAE/VAP (October 2008), MRSA infections (October 2008), and post-procedure pneumonia (October 2012). So there is some hope that HAI and MRSA will become better recognized. But what about MDROs?  Investigators from Wash U (including co-blogger Hilary) just published a research letter in ICHE that calculated the sensitivity of ICD-9 codes for various MDRO at their hospital between 2006 and 2015. The gold-standard was a culture at a sterile site or BAL/brochial wash culture with an MDR-Enterobacteriaceae, Enterococcus spp., Staphylococcus aureus, Pseudomonas aeruginosa, or Acinetobacter spp.

As you can see in their Table 1, apart from MRSA (after 2008 code added) and P. aeruginosa, ICD organism coding had poor sensitivity and MDRO/V09 codes were - terrible. The authors concluded: "ICD-9-CM diagnosis codes cannot be used to estimate the burden of MDRO infections in hospitals."  I think we'd all agree. I would have liked to see more information on the specificity and positive/negative predictive values of individual codes (I understand this was a Research Letter).  I'm not sure what the ultimate solution is, but perhaps SHEA or IDSA (or ASM) could work to update ICD-10 codes and come up with ways to encourage accurate coding for infectious diseases. If we don't make sure infections "exist" in administrative data, the field of infectious diseases might not exist for long.

image source

Donation

What a terrible couple of weeks. Hurricanes Harvey and Irma, not to mention a huge earthquake in Mexico, pummeled North America. If possible, one of the things that we can do in these situations is donate to recovery efforts. Here are a couple suggestions for places where you can donate:

UNICEF has sent teams to Chiapas and Oaxaca and has expanded their fundraising efforts to cover those affected by the hurricanes and earthquakes. Donate please

The five living past Presidents have started the One America Appeal, which initially responded to Harvey but has been expanded to assist with Florida's recovery. Donate please

Finally - and we have been hesitant to even mention this -  many SHEA members have completed races to raise funds for antimicrobial stewardship scholarships through the SHEA Education & Research Foundation's "Race Against Resistance." Runners have included fellow bloggers Tom and Scott. Not to be outdone, the University of Iowa has put together a team 5k run on September 30th.  We hope you can contribute to this important educational and prevention effort. Donate please

Thank you

Join The Race Against Resistance

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

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

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

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

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

In Memoriam: Standing on the Shoulders of Giants

In the past two months, we’ve lost two prominent healthcare epidemiologists, Drs. Walter J. Hierholzer, Jr. and Barry M. Farr. Each served a term as president of SHEA, and each mentored many other influential epidemiologists who carry on their work.

Walt spent almost a decade at our institution, the University of Iowa, and started a tradition of strength in infection prevention that exists to this day. Here is an excerpt from his obituary: 

Dr. Walter J. Hierholzer Jr., 82, Professor Emeritus of Internal Medicine and Public Health at Yale University of School of Medicine and resident of Guilford, CT, passed away on January 21, 2017. Born in Midland, MI to Walter and Florence (Rodammer) Hierholzer, he is remembered by his family and friends for his intelligence, warm sense of humor, and staunch support of the Democratic Party.

Dr. Hierholzer attended Albion College and the Yale School of Medicine with subsequent training in epidemiology at the University of Minnesota. He met his wife Bente while studying as a Fulbright scholar at the Biological Institute of the Carlsberg Foundation in Copenhagen, Denmark. As an Assistant Professor of Epidemiology and Internal Medicine at the Yale School of Public Health (1972-76), he made several trips to the Amazon to study the impact of infectious diseases on native Brazilian tribal populations. From 1976-85, Dr. Hierholzer was an Associate Professor of Infectious Diseases and Preventive Medicine at the University of Iowa and Director of Hospital Epidemiology Program overseeing statewide hospital epidemiology education. From 1985 until his retirement in 1999, he was a Professor of Medicine and Epidemiology at Yale and the Hospital Epidemiologist at Yale New Haven Hospital. 

Barry was hospital epidemiologist at the University of Virginia when I was a medical resident, and his impact on our field has been substantial. A passionate advocate of active detection and isolation (ADI) for prevention of MRSA and VRE transmission, Barry often sparred with us during the early months of this blog (which encouraged us to continue blogging, since it was evidence that somebody important was reading what we wrote!). Although we disagreed with his conclusions about ADI, there is no doubt that his strong advocacy sparked spirited debate and drew increased attention to healthcare-associated MRSA (HA-MRSA) infection in particular. Increased focus on this pathogen almost certainly played a role in the successful reduction in HA-MRSA that we’ve seen over the past decade. Here is an excerpt from a tribute to him written by Mitch Rosner and Bill Petri:

It is with great sadness that I report that Dr. Barry Farr, emeritus Professor of Medicine, passed away today. Dr. Farr received his medical degree from Washington University in St. Louis and a Master of Science degree in epidemiology from the London School of Hygiene and Tropical Medicine. He trained in internal medicine and infectious diseases at the University of Virginia. He spent the rest of his career on the faculty of the University of Virginia School of Medicine where he retired as the William S. Jordan Jr., Professor of Medicine and Epidemiology at the age of 52 due to physical disability from multiple sclerosis. Hospital Epidemiologist at UVA for 18 years and Chairman of the Master of Science Program in Epidemiology for 11 years, he mentored 18 postdoctoral fellows in research. He also was President of the Society for Healthcare Epidemiology of America, and Editor of the SHEA scientific journal Infection Control and Hospital Epidemiology. He co-authored 167 medical publications, 137 scientific abstracts for national scientific meetings, and co-edited two books entitled Catheter Related Infections. He was a leading authority on MRSA infections and his work in this field continues to inform clinical practice. 

In the past few years, Barry was a tireless advocate for patients with multiple sclerosis and he published an important book to help guide patients in avoiding complications due to the disease. For those of us fortunate to have known Barry, he was a tremendous mentor, a deep thinker with a questioning mind and a pioneer in quality improvement. We will greatly miss him and our thoughts and prayers are with his family.

When a dead horse is your only horse...

I’d like to thank Tom Talbot and Hilary Babcock, two of the authors of SHEA’s position paper on mandatory influenza vaccination of healthcare workers, for their response to my recent post on why I think this policy is misguided. Hilary and Tom are excellent hospital epidemiologists that I respect. Nonetheless, on this issue, I remain unconvinced by their arguments.

They point out that that I mischaracterized SHEA’s position being based on four nursing home cluster randomized trials, when in fact the position paper has 63 references. There are, indeed, 63 references, the majority of which do not address the impact of vaccinating healthcare workers on patients. In fact, most of the references lay out the biologic plausibility that vaccinating healthcare workers should have an impact on patients, as well as other issues, such as the impact of mandatory programs on vaccine rates. The biologic plausibility arugment is very nicely laid out in their blog post, and I agree with it completely. So, I’ll be more precise: SHEA’s best evidence for their policy is contained in the four cRCTs.

Tom and Hilary go on to cite newer studies that they believe support SHEA’s position, one of which is a cluster randomized trial from the Netherlands. I was not familiar with this paper so I reviewed it. In this trial, 6 hospitals were randomized—3 had an intervention to increase vaccination rates in HCWs and 3 did not. Significantly higher vaccination rates were demonstrated in the intervention hospitals. The patient outcomes were divided into adult and pediatric patients and the outcomes reported for patients were influenza and/or pneumonia and pneumonia. Influenza was not an outcome. Thus, the influenza rates cannot be determined. If the two outcomes are mutually exclusive, then the influenza rate is actually higher in the intervention hospitals (though not likely significantly so). For children, there was no difference between the intervention and control hospitals. And interestingly, the intervention hospitals had significantly higher HCW absenteeism rates, a metric Hilary and Tom argue as important for demonstrating the effect of employee vaccination. Thus, I don’t think this paper in any way supports mandatory vaccination.

Despite the studies published in the seven years since the SHEA position paper was published, there remains an irrefutable fact: there is no high level evidence demonstrating that vaccinating healthcare workers reduces influenza in hospitalized patients. I agree with Hilary and Tom that the four nursing home studies are a dead horse. Unfortunately, however, that dead horse is their only horse.

Everyone has opinions about infection prevention interventions biased by their own experiences and perceptions, and I’m glad that Tom and Hilary pointed out one of mine—bare below the elbows. As I write this post while on service, I’m, you guessed it, bare below the elbows! There’s clearly biologic plausibility that clothing can transmit pathogens to patients, but there is no evidence that following a bare below the elbows approach to patient care lowers infection rates, and in every talk I give on this topic I make that very clear. I would never argue that HCWs wearing white coats should be fired; otherwise, Tom and Hilary would have to be fired (based on their photos). And unfortunately, they missed the entire point of my post. I’m not arguing against vaccination of HCWs. My point is that you can’t mandate an intervention (and in this case threaten a person’s livelihood) when the intervention is not supported by high level evidence. In other words, you can’t mandate on opinion, but that’s exactly what SHEA did. Expectations for compliance with an intervention must be correlated with the strength of the evidence. 

SHEA made a huge mistake when they published this position. And seven years later, there’s still no published evidence that can bail it out. It was wrong seven years ago, and it’s still wrong. Healthcare workers in the US deserve better, especially from a professional society that prides itself on using science to guide practice.

Reporting bias: Missing the point of HCP influenza vaccine mandates

We invited our good friends Hilary Babcock and Tom Talbot, distinguished epidemiologists and co-authors on the SHEA statement regarding mandatory influenza vaccination of healthcare personnel (HCP), to respond to our previous posts on this topic.  Thanks, Tom and Hilary!

Disclaimer: This commentary solely represents the opinions of the authors and does not represent an official statement from SHEA

Nothing seems to ignite the fires of the Controversies blog like a few key infection prevention topics: CAUTI as an HAI metric, bare below the elbows, and the topic of a recent blog post, mandatory HCP influenza vaccination and the SHEA 2010 Position Paper. As authors on the 2005 and 2010 SHEA papers, we provide a different perspective on the issue.

A key misconception of opponents of mandatory influenza vaccination programs is the claim that the 4 cluster RCTs referenced in the recent post are the only evidence underpinning the position of SHEA (and the numerous other professional societies also endorsing such policies). The 2005 SHEA paper has 100 references while the 2010 paper has 63, a majority of which are peer-reviewed publications in the medical literature. The 4 RCTs noted are far from the only “papers on which SHEA based its recommendation,” as Dr. Edmond states and the De Serres paper implies.

These studies are not perfect by a long shot and the challenges of accurately studying the impact of HCP vaccination on patient outcomes have been nicely highlighted in analyses of these trials, of which there are several – the De Serres paper highlighted in the blog, a CDC analysis that came to different conclusions (and surprisingly was never featured as a blog post), and three separate Cochrane analyses (are there not enough topics out there for them to review??). We also encourage readers to closely review the detailed editorial that accompanied the De Serres paper for an excellent response to the many assumptions in their analysis. If only other infection prevention proposals were scrutinized as heavily as these 4 studies (cough, cough, we’re looking at you bare below the elbows . . . ). Of note, the limitations of these 4 trials were noted in the 2010 SHEA paper, which also cites the first Cochrane analysis in that discussion (despite claims to the counter).

What is missed in the arguments against mandatory programs (including the recent blog post) is the biologic rationale and additional supporting evidence for this strategy as part of a comprehensive infection prevention program. We refer readers to the 2005 and 2010 papers for more detail but summarize briefly here:

1. HCP (like our patients) can become infected with influenza.
2. Persons infected with influenza may not present with classical ILI symptoms. This is often missed in criticisms of vaccine effectiveness. Babcock et al demonstrated how poorly the ILI definition captures hospitalized adults with laboratory-confirmed influenza. Thus studies that look just at vaccine impact on ILI will likely miss true influenza outcomes, while also capturing infections due to other viruses not covered by influenza vaccination. Since clinical testing is usually prompted by stereotypical ILI symptoms, lab-confirmed influenza outcomes are also likely under captured. In addition, since hospital length of stay is shorter and most facilities do not have post-discharge surveillance for influenza, the impact in acute care facilities is more challenging to assess than in long term care settings. 
3. Persons infected with influenza can shed virus even with minimal or no symptoms. While not to the same degree as a coughing, febrile person, the role of asymptomatic infection has been noted in numerous studies of households and experimental challenges. A 6-year study from Hong Kong of a cohort of 824 households with an identified 224 cases of secondary influenza infection examined the relationship between symptoms and viral shedding (as detected on nasal and throat swabs). Shedding was detected before onset of respiratory symptoms in influenza A-infected persons but peaked on the first 2 days of clinical illness, while influenza B shedding peaked up to 2 days prior to symptom onset. So relying on HCP to stay home when ill (which they don’t anyway, see below) will not protect patients. 
4. HCP work while ill. Sadly, this is a huge issue, as nicely noted in several posts on this blog. Studies consistently note ~75% of HCP with febrile ILI admit to working while ill, a startling yet unsurprising fact that does not capture those with atypical, mild, or even asymptomatic infection. We completely agree that this is a major infection prevention issue. The SHEA 2010 paper notes the importance of “restriction of ill HCP from working in the facility” as part of a “comprehensive infection control program” to prevent healthcare-associated influenza (and other respiratory infections). We definitely support a stronger stance on the infection risk of HCP working while ill and the various disincentives for staying at home (e.g. leave policies where sick days and vacations days are in one lump “bucket”). Perhaps we need a new chapter of the Compendium focused on the prevention of healthcare-associated respiratory infections?
5. HCP have contact with patients at higher risk for complications from influenza than the general public. The privilege of that close relationship carries an obligation to do all we can to protect those patients. 
6. Many patients won’t be adequately protected by receiving the vaccine themselves. Proponents of mandatory vaccination frequently note the moderate effectiveness of the vaccine, and we completely agree on the need for a better vaccine. The suboptimal effectiveness only emphasizes the need to optimize immunity among those who are more likely to respond in order to prevent transmission of influenza in healthcare settings (to protect the “herd”). Most HCP are healthy and therefore more likely to have a robust immune response to vaccine than already ill patients, many of whom are elderly and/or immunosuppressed. 
7. Most agree that HCP should be vaccinated against influenza, though they may disagree with a ‘mandate.’ Extensive literature now demonstrates that a mandate is the most effective way to increase HCP vaccination rates. If it is an outcome (HCP influenza vaccination) that we all support, should we not encourage its use through the most effective method for high vaccination rates? 

Fortunately, as more institutions have employed a mandatory program, new evidence that further supports the need for HCP immunization that was not available when we wrote the 2010 paper has emerged:

• Researchers at the Denver Health Medical Center reported a decrease in employee absences during the influenza season following implementation of their mandatory program when compared to prior seasons of similar influenza activity. 
• In an analysis of the province-wide vaccination with masking policy in British Columbia, researchers noted a significantly reduced rate of HCP absenteeism due to all-cause illness in vaccinated vs. unvaccinated HCP during the first season of the policy. 

Even more important than the impact on HCP illness is the impact on patient outcomes:

• MD Anderson Cancer Center implemented a mandatory vaccine with masking policy and examined the impact of increasing HCP influenza immunization over the course of 8 years. The proportion of influenza infections that were healthcare-associated among patients significantly decreased and was significantly associated with increased HCP vaccination rates. 
• A cluster randomized trial in the Netherlands of HCP at six medical centers, where the intervention arms offered vaccination to HCP vs. no vaccination at control facilities, noted a significantly lower rate of healthcare-associated influenza among internal medicine patients at the facilities with the higher rates of HCP influenza vaccination (3.9% vs. 9.7% of patients). 
• In a study encompassing 7 influenza seasons and over 62,000 hospitalized patients, a significant association was noted between increasing influenza vaccine coverage among HCP and decreasing healthcare-associated ILI among patients at an Italian acute care hospital.
• Finally, a nested case-control study in France noted a significant association between lower rates of laboratory-confirmed healthcare-associated influenza among patients and higher vaccination rates among HCP.

We don’t have time to go into the ethical arguments for HCP vaccination or the need to broaden these programs to include all recommended immunizations for HCP, but we close with a noteworthy pronouncement made by the Board of the National Patient Safety Foundation’s Lucian Leape Institute: there are two “must do’s” for HCP to ensure patient safety, hand washing and HCP influenza vaccination. 

Time to stop re-analyzing those 4 poor cluster RCTs – that horse has been beaten to death.

M. chimaera update: SHEA webinar

Tomorrow (Monday, January 23 at 1 pm Eastern Time), Mike and I will be presenting an update on the global outbreak of heater-cooler device associated Mycobacterium chimaera. You can sign up for this SHEA webinar here (sorry for the late notice!). A CDC representative will join us for the Q&A.  Once it is done we'll either post a link to the webinar or make the slides available on the blog.

We hope you can join us!

UPDATE: here is the link to listen to the webinar. 

Training Course in Healthcare Epidemiology and Infection Control (Bochum Germany)

Happy 2015 ESCMID-SHEA Training Course Students and Faculty

The ESCMID-SHEA Training Course in Healthcare Epidemiology and Infection Control has been redesigned. Instead of predominately lectures, the new course model now includes three distinct tracks. The first track is an interactive and practical exercise on how to analyze and respond to a high-rate of surgical site infections in your hospital. The second track covers data analysis of a possible outbreak of C. difficile infections. The third track includes 4 interactive masterclasses led by highly experienced hospital epidemiologists covering topics such as outbreaks, responding to high endemic rates of HAIs, infections in surgical populations and other topics. 

The course was pilot tested last year in Cairns, Australia with great success (see above) and the instructors can't wait to build on that success this fall in Europe. We hope you can join us 4-7 October 2016 in Bochum, Germany. Registration is via the Aesculap Akademie website.

Not just another guideline

Why is this man laughing? Because he co-authored an awesome antibiotic stewardship guideline!

The updated antibiotic stewardship guideline has been released, and is available at the Clinical Infectious Diseases website, and in pocket card and mobile versions. While the guideline will undoubtedly be essential for those tasked with establishing and running stewardship programs, it isn’t going to be frequently referenced by prescribers. 

Instead, treatment guidelines for specific clinical syndromes are more likely to guide prescribing decisions, either by direct application or via their incorporation into facility specific practice guidelines or CMS measures. Thus the impact of the stewardship guideline will be limited unless stewardship principles are also incorporated into treatment guidelines, pathways, and quality measures. This point was made in a recent editorial by Brad Spellberg, Arjun Srinivasan and Chip Chambers, and I know that HICPAC plans to summarize the stewardship principles that should be incorporated into all ID-related treatment guidelines. 

Ensuring that antibiotic stewardship principles are considered carefully when infection-related quality measures are established is a continuing challenge—once a measure is tied to payment and/or public reporting, the law of unintended consequences takes over, including consequences for antibiotic use. We learned this with the ill-fated “4-hour rule” for treatment of community acquired pneumonia, which likely led to an untold number of inappropriate antibiotic doses and C. difficile cases, and we’re struggling with it again around the new sepsis measure. 

Finally, truly informed stewardship awaits a lot of research and development progress: to better establish dose and duration of therapy for common conditions, to improve diagnostics to allow more rapid directed therapy, as well as improved capacity to distinguish bacterial, fungal and viral etiologies, to more precisely determine the relative impact of different antibiotics on host microbiota (and the implications thereof), etc., etc., etc. Someday, I hope, we’ll be able to look back at the 2016 guideline and marvel at how rudimentary it is—for now, though, it’s excellent, so go read it!

Photo credit: US News and World Report

SHEA Spring Meetings 2007, 2011, 2015 and Beyond?

A decade ago, I was a young associate professor of Epidemiology at the University of Maryland School of Medicine in Baltimore. One afternoon I received a call from Dr. Trish Perl, then President of SHEA and crosstown colleague. Two years earlier, she and I had met when we assisted with the infection control of Bob, an Atlantic Bottlenose Dolphin at the National Aquarium, who had been diagnosed with Mycobacterium abscessus pneumonia. She was not calling about marine mammals this time, but rather was asking me to serve on the 2007 SHEA Annual Meeting Planning Committee, as the local "Baltimore" representative. It was an amazing experience. For one, it was when I met future colleague, friend and co-blogger Dan Diekema and other mentors and colleagues - see the 2007 AMPC roster below.

Over the years I've been asked to serve on many other meeting committees including the last old format SHEA Scientific Meeting in Dallas (2011) and the first combined meeting, IDWeek 2012. As 2016 represents my last year on the SHEA Program Planning Committee, I've been looking back over the old committee rosters and reminiscing. What struck me most, besides the amazing colleagues I've crossed paths with, is the overwhelming presence of MDs, specifically ID-trained, on the committees. Looking at the rosters from 2007 (above) and 2011 (right) and excluding SHEA staff, 94% were ID physicians over both years.

The preponderance of ID physicians is not surprising, given that SHEA was founded by ID physicians and our board of directors roster is made up of ID physicians. However, the science and practice of infection prevention and stewardship is evolving into a broader multidisciplinary effort. We now frequently collaborate and learn from a variety of well-trained scientists and clinicians including medical sociologists, medical anthropologists, epidemiologists, biostatisticians, human-factors engineers, infection preventionists, general internists, MBAs, health economists, pharmacists, microbiologists and health psychologists among others.

When faced with the daunting task of walking in the footsteps of prior co-chairs, Lindsay Nicolle, Scott Fridkin, Charlie Huskins and Dan, we recognized that we had an opportunity to broaden the appeal of the conference and strive towards a truly multidisciplinary program. So in 2015, working with the SHEA board and staff, Susan Huang and I convened a Program Planning Committee (figure below) with 42% of its members trained in fields other than infectious diseases. 

This is not to imply that ~40% is the correct balance. Maybe it should be closer to the 15% of 2016. Perhaps future spring meetings will have an implementation focus and over 50% of the planning committee could be experts outside of infectious diseases and other years the focus could be diagnostics and the committee could be loaded with microbiologists. 

The important thing is that we realize that clinical and scientifically, SHEA and our meeting should not be defined by what we were (ID physicians) and what we are not (APIC), they should be defined by what we hope to achieve. And if we truly hope to prevent healthcare-associated infections and the emergence of antimicrobial-resistant pathogens, we need more than ID physicians. Plus, I think it will be a lot of fun!