Guest Post: Charlie Garland from the Healthcare Innovation & Technology Laboratory (HITLAB*) @ Columbia University Medical Center is conducting a nationwide survey of Infectious Disease physicians and pharmacists around treatment patterns for carbapenem resistant bacterial infections, and he would like your participation and expertise to help in this research. This survey will only require 10 – 15 minutes to complete, but the results will be extremely valuable. We will gladly share the results of our research with each participant, which will help you and your colleagues to understand how your individual strategies compare to those of your peers – within your region, and across the US.
The link below will connect you to this survey, which will ask you: · A few demographic questions about the hospital at which you practice.
· 5 scenario-specific questions around treatment strategies that you would most likely employ in each case.
· 7 follow-up strategies, based on different patient responses to the initial Rx.
· An option to enter your name/email if you’d like to receive the survey results (aggregated).
The information we gather will be de-identified and only reported in the aggregate.
Please feel free to forward this link on to colleagues whom you believe would like to participate. We are asking participation of infectious disease physicians, fellows, residents, interns, and pharmacists.
Kind regards,
Charlie Garland, HITLAB/Senior Fellow Healthcare Innovation & Technology Laboratory
(@ Columbia University Medical Center) *The Healthcare Innovation and Technology (HIT) Lab is a cross-disciplinary, academically based, research cooperative located at the Columbia University Medical Center in New York City. The HIT Lab consists of Columbia faculty, staff, students, alumni, and members of the Washington Heights community collaborating to improve healthcare through thoughtfully designed and implemented technology
"You may ask yourself, well, how did I get here?" - the Talking Heads
It's been a busy week in antibiotic resistance. From Tuesday's MMWR early release identifying terrifyingly large increases in CRE until today, there has been non-stop media coverage. This morning, I had a long discussion with a colleague about CRE and it got me thinking about how we got to this point. As Maryn McKenna so astutely said this week: "it will be interesting to see whether the news sinks in this time." So, how did we get here?
1981: What we now call AIDS was recognized as a clinical syndrome. Thus began the cascade of infectious diseases research towards a full-scale and massively-funded response to the AIDS crisis. This has been an incredibly successful, if not yet complete effort. At the 2011 IDSA meeting, Cornell's Trip Gulick said that we now have 10,000 possible combinations of antiviral therapy agents for HIV. Thirty years after the virus was discovered in 1983, the progress has just been incredible. Sure, we've not yet achieved a significant number of cures and an effective vaccine remains just out of reach, but if you'd asked most of us in 1990 if we'd wanted to switch places with 2013, we would have said yes in a heartbeat.
2013: Most ID research efforts still target HIV and other viral pathogens. As we published last year, 2009 NIAID funding for HIV was $1.3 billion, while funding for all ESCKAPE pathogens was around $49 million. When we reported this disparity, it seemed quite obvious that we needed to fund more research of antibacterial resistant pathogens. However, nothing is ever that easy. One of the peer-reviewers of our paper made the excellent point that the "historically poor funding for antimicrobial resistance over the years along with the exit of pharma from the field has led to a lack of significant infrastructure. There may not be enough productive labs to send more money to at this point." So, even if the US wanted to fund more research, it may take time to train or retrain investigators to undertake the relevant research.
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Now that I've shared some brief thoughts on why we are where we are, I have some further thoughts on where we should go. First, as I said earlier this week, we need a national response to CRE and antimicrobial resistance in general. This response needs to be horizontal in approach, as Mike Edmond and Dick Wenzel recommended several years ago. For it is quite clear that if we follow the vertical approach recommended by the CDC and others, swab for CRE and isolate, that this will bankrupt hospitals and ultimately fail.
This surveillance approach will bankrupt us, because CRE isn't the only "nightmare" in our hospitals. Back in 2010, when Dan was discussing MRSA on NPR, he said so eloquently: "MRSA is not the only bad bug out there. It's just the most famous." And along with MRSA, we have VRE and ESBL and C. difficile and Acinetobacter and MDR-Pseudomonas. You see, we might not be able to take this single-hospital outbreak approach and extrapolate it to the entire country and 10+ pathogens. And if there is one lesson we should be taking away from the NIH CRE outbreak it's not that new-fangled whole genome sequencing stopped the outbreak (because it didn't), it's that the outbreak spread and killed many patients despite herculean efforts to detect and eliminate it. Furthermore, if we target MRSA like many hospitals are now doing with chlorhexidine (CHG) baths, this approach could select for Gram-negative bacteria like CRE.
My recommendations:
(1) Invest significantly in antimicrobial discovery. Apart from the need for new treatment options, optimal control of resistant pathogens may depend on availability of effective antibiotics.
(2) Invest in studies to improve compliance with hand hygiene – only 4 studies on this topic since 1980 per a recent Cochrane Review. Compliance is terrible, but currently the approach is to blame healthcare workers and not figure out how to help them easily clean their hands.
(3) Study universal gowning and gloving (several studies are ongoing). Dentists wear gloves with every patient, why not doctors?
(4) Undertake studies to further optimize environmental source control
(5) Actually study antimicrobial stewardship. Stop yelling at patients and clinicians to not use antimicrobials. Actually fund studies that use advertising and other other messaging techniques that have a chance to be effective.
Oh, and no more ridiculous hand hygiene song and dance videos...unless they include folks like the Talking Heads...
There is an early release MMWR out today describing the recent trends in carbapenem-resistant Enterobacteriaceae (CRE) using data from the CDC's National Healthcare Safety Network (NHSN) and the Surveillance Network–USA (TSN). CRE infections, such as UTIs or intra-abdominal infections, cannot be treated with currently available antibiotics. The results of the MMWR study are not surprising - there are more CRE now - yet I find them rather chilling.
The proportion of Enterobacteriaceae that were CRE rose from 1.2% in 2001 to 4.2% in 2011 in NHSN hospitals and to 1.4% by 2010 in TSN facilities. In Klebsiella species, the situation is dire with 10.4% classified as CRE in 2011. By 2012, 4.6% of all facilities, 3.9% of short stay hospitals and 17.8% of long-term acute-care hospitals reported at least one CRE in their facility.
So things are pretty bad, at least 17.8% bad.
What can we do about this? This is what they say in the abstract: "Interventions exist that could slow the dissemination of CRE. Health departments are well positioned to play a leading role in prevention efforts by assisting with surveillance, situational awareness, and coordinating prevention efforts."
Which interventions? Certainly there are no evidence-based interventions, unless we call an uncontrolled quasi-experimental study evidence. The CDC authors made reference to VRE control efforts in the Siouxland, MRSA control efforts in The Netherlands and CRE control efforts in Israel. I think these are poor and overly optimistic comparisons for several reasons. For one, the first two efforts targeted Gram-positive bacteria and it's unclear if we can extrapolate these to control efforts targeting MDR-GNRs. For example, we have effective antibiotics for VRE and MRSA (quinupristin/dalfopristin-approved in 1999; linezolid-approved in 2000, daptomycin-approved in 2003) but not for CRE. Additionally, we can decolonize for MRSA but not CRE.
However, the most important aspect of the Netherlands and Israel examples were that they instituted NATIONAL RESPONSES aimed at MRSA and CRE. There are no such national efforts here in the US targeting CRE. This is what we have in the US per the MMWR report: "six states have made CRE reportable, and three additional states are actively pursuing this option." This is not a national response. This is a national tragedy. We can't expect CDC to say they can't handle the problem and we can't expect states to say they can't handle the problem. They are working their butts off with minimal support and no national will for a coordinated response. If we don't have a national response soon - it will be too late, but I'm not holding my breath.
I will leave you with an excerpt outlining the Israeli national CRE response from Mitch Schwaber's excellent report in CID. Do you think we have anything close to this going on here in the US? Me neither.
Update: Looks like NPR's "All Things Considered" will post an audio discussion of the CRE issue around 7pm ET here.
Why is it that the DOD can ask for more money to fight their wars but CDC can't? It seems to me that the fight against resistant bacteria is a war! - enp
I was interviewed by Peter Eisler of USA Today about a month ago concerning the recent NIH KPC Outbreak. His investigative report on carbapenem-resistant Enterobacteriaceae (CRE) was just published today and I found it a very good read. The report centers around a CRE outbreak that began four years ago at the University of Virginia Medical Center and continues there to this day. The article is particularly interesting when you focus on the quotes from all of the other HAI-prevention folks in the article. However, I also thought as I was reading it, what would Dan and Mike have highlighted if they'd posted on this same article?
I suspect that Dan would have wanted to highlight how difficult infection control becomes when gene/plasmids cross species during outbreaks and how this strongly impacts case definitions as you investigate. He might also point out how this limits the utility of whole genome sequencing, since the plasmids merrily skip from one species to another. I think that Mike might have pointed out that the vertical control barriers, like nasal PCR, set up to prevent MRSA transmission are not very effective at preventing the spread of non-MRSA pathogens like CRE. He might suggest that a continuous and relentless focus on horizontal measures, like hand-hygiene, would be most effective. Dan and Mike would both have been correct, but I have a different take...
My take is that CDC is on the wrong side of this debate and this has me very worried. Now, I don't remember exactly what was said about HIV during the 1980s, but I suspect there was a realization that something needed to be done and that significant investments would need to be made in its treatment and control. I'm not suggesting that CDC should flame fires of panic, but I wonder how long we can rely on the same old, largely ineffective, tools for outbreak control - patient isolation, subpar environmental control, inadequate hand-hygiene improvement bundles, lack of effective and novel antimicrobials - before CDC asks for help...and more funding.
So here are some select quotes from the article with my concerns bolded:
CDC:
"We're working with state health departments to try to figure out how big a problem this is," says the CDC's Srinivasan, noting that his agency can pool whatever incidence data states collect. "We're still at a point where we can stop this thing. You can never eradicate CRE, but we can prevent the spread. ... It's a matter of summoning the will."
The rest of us:
"In the Chicago area, where scores of CRE infections have been found since 2008, studies show that about 3% of hospital patients in intensive care carry the bacteria, says Mary Hayden, director of clinical microbiology and an infectious-disease doctor at Rush University Medical Center. Those same studies have found CREs being carried by about 30% of patients in long-term care facilities." "We have to think about a new approach, a regional approach, to controlling these organisms, because … no facility is an island," Hayden says.
"My concern is that there aren't a lot of methods in our tool kit that are significantly effective in curbing the spread of these infections," says Eli Perencevich, a professor and infectious-disease doctor at the University of Iowa's Carver College of Medicine. If unchecked, "these (bacteria) are going to greatly impact the kind of surgeries (and) treatments we can have," Perencevich says. "We're entering the post-antibiotic era; that's a very big problem."
"If you look at the current pipeline of antibiotics (in development) … none of them really is going to be active against these bacteria," says Gary Roselle, director of the Infectious Diseases Service for the Department of Veterans Affairs health care system. "The reality is, (CRE infections) are remarkably difficult to treat, they often have bad outcomes … and they're increasing nationally," adds Roselle. "I'm assuming this is going to get worse, and there likely won't be new antibiotics to treat it in the near future, so the focus has to be on prevention."
"So even if I had a perfect program to stop all patient-to-patient transmission in the hospital, the maximum impact I could have would be a 60% reduction in prevalence," says Brian Currie, the hospital's vice president for research and an assistant dean at the affiliated Albert Einstein College of Medicine.
"We have continued to have patients with CREs that are related to this (first) event," Costi Sifri, the hospital epidemiologist at UVA, says. "We haven't been able to close the door on this. ... I'm not sure you ever can."
