Recognizing the Value of Infection Control in Addressing the AMR Crisis

One of the challenges that all infection control and QI programs face is obtaining the necessary funding to complete all their required activities such as surveillance, reporting and prevention. Anthony Harris from the University of Maryland spent a great deal of time (e.g. SHEA White Paper on Necessary Infrastructure) as SHEA President pushing for increased resources for hospital epi activities. In a recent BMJ Quality and Safety editorial, Anthony offered suggestions for advancing the recognition and resources for infection control and QI activities, including societies (i.e. SHEA, APIC, ESCMID) partnering with governments to create comprehensive recommendations for infection control programs and funding.

Specifically, he recommends:

(a) guidelines by major organisations outlining the optimal reimbursement and full time employee (FTE) of hospital epidemiologists and infection preventionists for healthcare facilities in various settings. Currently, agencies such as CMS list certain conditions of participation for institutions relative to infection control and soon to be antibiotic stewardship; however, details of these requirements are vague and should be expanded

(b) as reimbursement moves away from fee per service and more towards quality outcomes driving reimbursement and penalties, we need more effective and novel methods of directing resources for day-to-day infection prevention. For example, an infection prevention fee could be imposed on all procedures that require significant infection prevention resources such as surgery or central line insertion and maintenance

(c) funding for state health departments to assist individual hospitals in establishing effective infection prevention programmes

(d) novel reimbursement models such as a fixed fee per surveillance culture reviewed, a fee for each chart reviewed to assess the appropriateness of antibiotic selection or an hourly fee for performing outbreak investigation may be warranted

(e) certification requirements for hospital epidemiology and QI experts that will help recruit and establish more experts to the field.

The full editorial (free full text access) is well worth reading. (COI alert: I'm a co-author)

Guest Post: Thinking about Contact Precautions

Anthony Harris, MD MPH

This is a guest post from Dr. Anthony Harris, Professor of Epidemiology and Public Health, University of Maryland School of Medicine.

I have a lot of admiration for this blog and in the spirit of academics, I would like to share my somewhat different interpretation of the contact precautions literature. I offer three points for your consideration:
 
1. Contact precautions do not lead to an increase in adverse events: 

Instead of the frequently cited small observational studies, I think it is most important to focus on the one randomized trial that evaluated adverse events associated with contact precautions (I acknowledge my bias in that it is the study I led). A randomized trial should most often trump observational studies especially since it's near impossible to control for confounding by indication, i.e. why was the patient placed on contact precautions. In fact, the latest analysis of our randomized trial data showed a trend towards decreased adverse events in the universal contact precaution arm. (See: Croft L et al. Clin Infect Dis. 2015 Aug 15;61(4):545-53). To quote from the Conclusion: "Concerns of adverse events resulting from universal glove and gown use were not supported." So we should be clear that other than the cost issues of gloves and gowns no high level study has shown any adverse events from contact precautions. Healthcare workers do go into the patient room less often when the patient is on contact precautions but this has not been shown to lead to an increase in adverse events. In my experience (and the data supports this), healthcare workers just bundle their activities and thus perform the same activities in the room with fewer visits.

2. Methodological problems in studies that have removed contact precautions: 

Studies that show no effect of removing contact precautions have serious methodological problems. The largest problem is that they are incredibly under-powered. The studies that show “no difference when you remove contact precautions” are too small to detect a difference and thus may falsely conclude that removing contact precautions is safe.

3. Need a better solution before removing the current standard of contact precautions: 

As much as I would love to stop wearing gloves and gowns, antibiotic-resistant bacteria are a continuing problem. They are not going away and other than MRSA, they are not decreasing. Until we have better solutions, I believe that we should not be abandoning contact precautions. This is particularly true in high risk settings such as the ICU. In the ICU where acquisition of an MDRO leads to infection 20-30% of the time during the index ICU admission, the stakes are too high not to prevent patient-to-patient transmission. I believe that the phase 0, phase 1 and phase 2 data on contact precautions are strong and the biologic plausibility that they prevent patient-to-patient transmission so strong that I don’t think we should abandon contact precautions based on underpowered "removal studies" and an adverse-event literature with few studies with strong internal validity. Of course there are certain settings and certain bacteria where removing contact precautions might make sense and these scenarios should be studied using large, sufficiently powered and methodologically sound trials.