Playing Nice: Infection Control and Clinical Microbiology in the Pay-For-Performance Era

As it's probably clear, it's been a great honor for me to work (and blog) with Dan and Mike over the past 8! years. One of the things that stands out when talking shop is their ability to see both sides of an argument even while pushing for the changes they support. Many times, their ability to see both sides clearly is possible because they've lived both sides - Mike has been an ID chief and hospital epidemiologist and is now our CQO and Dan is an ID chief, hospital epidemiologist and clinical microbiologist. You know, if I was a fellow or faculty member looking for a hospital epidemiologist position with great mentorship and support, I would move to Iowa...but I digress.

One specific area where understanding competing goals is critically important is the interplay between the increasing sensitivity and precision of microbiologic tests and the growing pressure to reduce HAI. As you can imagine, with 3% of CMS payments potentially at risk, anything that could impact HAI rates in a negative fashion is bound to be a flashpoint for hospital administrators. With that in mind, I point you to Dan's excellent commentary just published in JCM that examines the implications of advances in microbiological testing on HAI rates and provides specific suggestions for how hospital epi programs and clinical microbiology labs can work together to respond to these changes.

Initially, Dan provides three scenarios where changes in the micro lab could directly impact HAI rates (1) The effect of MALDI-TOF on CLABSI rates (2) The shift from EIA to nucleic-acid amplification tests (NAAT) for C. difficile detection and (3) Pressure to block urine culture ordering to reduce CAUTI. After delving into the current CMS reimbursement landscape, the unintended consequences of improvements in diagnostic testing and the use/misuse of surveillance definitions, he provides six valuable recommendations that clinical microbiology labs (CML) and infection prevention programs (IPP) should consider:

(1) CML leadership should select diagnostic approaches with the goal of improving individual patient outcomes

(2) Hospital and IPP leadership should not pressure the CML to alter diagnostic practices based on the need to demonstrate lower HAI rates for pay-for-performance measures. 

(3) Public health authorities (CDC/NHSN) must be proactive in adjusting HAI metrics to changing CML technology

For recommendations 4-6, you're gonna have to read his commentary. But a hint at #6 -  CML and IPP leadership need to collaborate and advocate for their needs, because, unlike at Iowa, both sides aren't always present in the mind of a single person.

Bloggers in the News: Quarantine of Uninfected Health Care Workers

Earlier today MSNBC put Dan in the middle, Hollywood Squares style, and asked him very good questions about SHEA's recent press release that supports active monitoring but warns against mandatory quarantine of health care workers. After watching this, my hope is that future discussions are this informative. Great work Dan.

 

Ebola update: Dallas and Airport Screening

It's been another eventful day. We've learned the unfortunate news that Eric Duncan, the index patient with Ebola in Dallas, has passed away. There have been concerns about further transmission to three other Spanish healthcare workers and that the initial nurse may have contracted the virus through breaking PPE removal protocol. There is even news that a second person in Dallas might have acquired Ebola through contact with Mr. Duncan or his surroundings. President Obama announced increased screening at the five US airports that account for 94% of entry flights carrying people from West Africa. Finally, NYT Science Reporter Carl Zimmer said that "worrying about Ebola becoming airborne, is like worrying about wolves evolving wings."

You could read all of these reports and more but the quickest way to catch up on today's Ebola news is to listen to Dan Diekema's interview on this afternoon's PRI The World. Somehow, Dan pulled away from his SHEA presidential duties and IDWeek sessions to record the interview that I've posted below.

 

Ebola: Hospital Epidemiologists in the News

It's been amazingly active week for hospital infection control with adult deaths and paralysis in children linked to Enterovirus 68 and there have also been some issues with Ebola. Practically every Hospital Epidemiologist* has been called upon to explain the transmissibility of Ebola and describe how they've been planning to protect healthcare workers and the community. Of course, I can't possibly list all of the mentions in local, national and international media, but if you have a particular clip that you'd like us to post, let us know.

I've been impressed by the clarity and skill that my SHEA colleagues have demonstrated. For example, earlier today Dan was on Public Radio International (PRI) discussing the difference between the virulence and contagiousness of infections and how it's easy to confuse the two. Specifically he said "In the case of Ebola, it is not true that it is airborne, it's not true that you can catch it just by being in the same room as an infected person. It really does require direct contact." Head on over to PRI, to hear the whole interview.

Kent Sepkowitz was on CNN yesterday describing the contagiousness of Ebola with the money quote: "so the super contagious body compartment is blood and it's blood and it's blood." And one of the stalwarts of hospital epidemiology and mentor to many, Leonard Mermel, was on MSNBC's All in With Chris Hayes tonight describing the well-developed screening algorithm that's been implemented at Rhode Island Hospital. I've added the video below. If you want to jump directly to Len Mermel's discussion, it occurs around 12:00. (apologize for the brief ad)

*A hospital epidemiologist is typically an infectious disease physician specialist who develops infection control plans to protect patients and healthcare workers in clinical settings including acute care hospitals and long term care facilities. During outbreaks the hospital epidemiologist helps identify the source of the infection and determines how best to contain its spread. They educate clinicians about the optimal ways to prevent infections (e.g. hand hygiene), while also tracking the use and misuse of antibiotics and the emergence of antibiotic-resistant bacteria. Other goals include preventing post-operative surgical wound infections and infections associated with central venous catheters. They are each hospital's very own disease detective!

What's happening with Staphylococcus aureus?

Antimicrobial resistance surveillance systems are critically important for guiding empiric antibiotics, antimicrobial stewardship programs and hopefully therapeutic and prevention research efforts. While it is true that surveillance always seems to show things are getting worse, it's the speed with which things change that is also important. With that in mind there are two recent reports from a national surveillance study that provide important data in regards to the magnitude and trends of resistance and molecular epidemiology among S. aureus and MRSA clinical isolates. (COI alert: both were authored or co-author by Dan)

Both studies used a sample of 4,131 clinical specimens submitted as 100 consecutive isolates from 43 US Centers during the last half of 2011. The first study published in AAC reported MIC distributions of all isolates stratified by MRSA and MSSA. 51% were MRSA. Over 95% of both MRSA and MSSA isolates remained susceptible to ceftaroline, tigecycline, daptomycin, linezolid, vancomycin, tetracycline and TMP-SMX. Thus, both from an empiric and definitive therapy standpoint, we have many treatment options available. Of the 2,093 MRSA isolates, 60 (2.9%) were hVISA positive via either one or both available screening tests and 25 (1.2%) were confirmed as hVISA. This is three times higher than in 2009 when only 0.4% were hVISA. The paper nicely provides details concerning the sensitivity and specificity of the screening tests for those interested.

The authors also reported a significant increase in high-level mupirocin resistance from 2.2% in 2009 to 3.2% in 2011 when all isolates were analyzed and from 2.8% to 4.0% when restricted to MRSA. The authors correctly state that recent trials highlighting the efficacy of universal mupirocin decolonization will only lead to greater selective pressure for these strains and increase their prevalence. This needs to be watched carefully.

In this month's ICHE, the authors published an analysis highlighting the molecular epidemiology of the MRSA stains using the same cohort. 30% were hospital-onset by the 48-hour rule and 64% were PVL positive. USA300 dominated in all strata (source, age, census region) except from lower respiratory tract isolates and in patients greater than 65yo. Of the 173 spa types identified, 51% were t008 and 18% were t002. 48% of all MRSA strains were the composite type (USA300/t008/SCCmec IV). See the figure below comparing it to the next most prevalent composite type (USA100/t002/II), which was found in 11% of isolates. I encourage you to read the entirety of this paper, as the authors discuss the possibility that MDR-clones of USA300 could emerge since it's now firmly established in the healthcare environment. Hopefully Dan will chime in with some comments. My take-away: USA300 = MRSA and MRSA = USA300, at least for now.

2013 Studies in Memoriam - A Tribute to Studies Almost Lost

Each year the Academy Awards honors those actors and directors who've died in the prior year. It's one of my favorite tributes. Recently, I found myself with a stack of unread journals about four feet high and one of my routines is to clean my office before the start of each year. Thus, I am catching up on what studies I missed or failed to mention when they were first published. This post is a tribute to those studies that have "almost" died in my journal pile...happy holiday reading...

1) I'm particularly embarrassed that we haven't yet mentioned this review written by Dan. He and Michael Pfaller published a review in the June 1 CID on the promise of rapid microbiological detection of MDRO for infection prevention. Sections cover MRSA, VRE and MDR-GNR. What I really like about this review is that it covers the barriers to successful implementation of rapid detection including the "post-analytic" turn-around time and the current dearth of data supporting the clinical utility for many of these approaches. A must read. (NOTE: Currently the CID website is down, I will update with a direct link to the paper once they are back online)

2) Bevin Cohen from Elaine Larson's group at Columbia published a retrospective cohort study in JGIM investigating gender differences in BSI and SSI risk.  The study included three years (2006-2008) of data from a single center. Odds of these HAI were between 15 to 22% lower in women.

3) John Hollingsworth. Sanjay Saint and colleagues from the University of Michigan published a systematic review and meta-analysis of non-infectious complications of indwelling urethral catheters in Annals this past fall. After identifying and reviewing 37 studies they found that minor complications were quite common. For example, urinary leakage ranged from 10.6% in short-term catheterized patients to 52% in those with long-term catheterization. Serious complications were also quite common. If CAUTI isn't reason enough to remove a urinary catheter, these non-infectious complications should be!

4) And to follow up on the urinary catheter removal theme, there was a meta-analysis published in BMJ that quantified the benefits of antibiotic prophylaxis after urinary catheter removal. When analyzing seven controlled studies (5 from surgical patients), they found antibiotic prophylaxis was associated with an absolute risk reduction of 5.8% for UTI and a risk ratio of 0.45. I suspect there are trade-offs in increased antimicrobial resistance that should be assessed before this is more widely adopted.

Credit: James Taylor at the 2010 Academy Awards - one of my favorite tunes

Global Conspiracy to Hinder US MRSA Control Efforts Uncovered. US and Swiss Scientists Implicated

I was going to title this post "Making Shit Up" but then thought better of it. First of all, profanity can be offensive to some and for reasons that will hopefully become clear, there was a lot of crap written but some of it wasn't made up. It was just that it was twisted and some really great scientists and their science were denigrated. In addition, many scientists were mentioned in an unprofessional manner (first names?) and perhaps some points bordered on ad hominem. Thus, rather than limiting myself to name calling, which lies below ad hominem on Paul Graham's Hierarchy of Disagreement, I've decided to aim a little bit higher...so let me begin my counterargument.

First, please step away from this post and go read the 2-page commentary just published in AAC titled: "A Perspective on How the United States Fell behind Northern Europe in the Battle against Methicillin-Resistant Staphylococcus aureus."

Some thoughts. First, the authors suggest in their title that the US is falling behind Northern Europe in MRSA control. Little evidence is provided to support this claim other than that the proportion of S. aureus infections caused by MRSA is higher in the US. No mention is made of livestock-associated MRSA or MSSA or even MRSA related mortality. In addition, the authors focus on only one aspect as a possible cause for this difference between the US and Northern Europe - the US doesn't have legislatively mandated universal active detection and isolation (ADI).

The authors explain that everything would have been wonderful in the US if the 2003 SHEA guidelines recommending ADI were just followed. No mention was made of the fact that Northern Europe lies at the latitude of Anchorage Alaska and that environment might play a role. No mention was made of other potential differences that could influence the carriage rates of this human commensal. And when you read it closely, you realize the commentary authors aren't just upset that the US lacks mandatory ADI but conjure evidence that there's actually an anti-ADI conspiracy aimed at preventing legislative mandates. One supported by antisurveillance activists named Huang and Huskins, and mysterious JAMA Swiss folks, and Diekema and Climo and meddling yet unnamed kids like Weber and Edmond writing position statements and editorials closing cases.

According to Kavanagh et al. it all started with the 2006 HICPAC statement that suggested to consider ADI while requesting more evidence and the SHEA-APIC position paper in 2007 by Weber (and Huang and Huskins) that came out against legislative mandates for ADI. You see, according to Kavanagh and his colleagues, Huang and Huskins would later spend years writing grants and completing complicated and intentionally imperfect studies at a huge personal cost in a twisted antisurveillance plot! Even against these odds, the US Congress held a hearing to push through mandatory ADI but just then unnamed JAMA Swiss folks published a study finding universal ADI ineffective and Diekema and Climo agreed as much in their editorial. Even if we overlook the obvious conspiracy given the timing of the publications, how can these JAMA authors live with themselves suggesting high quality studies overwhelm prior uncontrolled quasi-experimental studies? - the nerve!

But it gets worse (or better)! The authors then highlight the VA MRSA study but suggest that the only reason it was published was that MRSA activists demanded it. And to further prove the conspiracy, they point out that this fantastic study was published in the very same issue of the NEJM as the Huskins STAR-ICU study finding no benefit of ADI. Yup - fact. They then mention limitations (however valid) of the STAR-ICU study while neglecting any potential limitations of the VA study. Very smooth.

The conspiracy theorists authors lose me a bit when they say the US demands surveillance for CRE and HIV and hepatitis C without evidence, and wonder why there's such a high bar for MRSA. It's just not fair!

Further evidence of a conspiracy is offered when they point out that two reviewers of an AHRQ systematic review were none other than the aforementioned Huskins and Diekema! And then it really gets strange. The authors point out that the AHRQ review gave more weight to the higher quality studies that were negative compared to poorly controlled studies that found a benefit. As I read this paragraph I almost become sad, as they basically lost the debate right there. They even mentioned hepatitis C screening again and plead that MRSA ADI evidence is maybe even probably hopefully better. Finally, the REDUCE-MRSA trial by Huang and the accompany editorial by Edmond were mentioned and criticized, you know, because.

They conclude with saying that this whole anti-ADI conspiracy has occurred with the sole purpose of avoiding legislative mandates. They correctly point out that the best way to avoid such mandates is to base clinical decisions on the best available evidence. Fortunately for our patients, that is exactly what we are doing now. We are using the best available evidence as produced by Huskins, Huang, Climo, Diekema, Edmond, Swiss folks like Harbarth and many other colleagues from our ever-growing, evidence-based field of infection control. You know, ADI may be indicated in some settings but not all settings and the way to determine where and when is through more high-quality studies. And there is no conspiracy.

57 Days of Diarrhea: Iowa and Nebraska Cyclospora Outbreak

As if living out here in the heartland wasn't exciting enough, news is quickly spreading (although not as quickly as the disease and ensuing panic) of a cyclospora outbreak in Iowa and Nebraska. Recent reports suggest that there have been at least 18 cases in Nebraska and perhaps 25 in Iowa. The Iowa Department of Public Health reports that as of Monday there were 22 cases and that the outbreak seems to have begun in mid-June. No source has been identified. What's a bit interesting is the focus in the IDPH brief and subsequent media reports on a 57-days duration (if untreated).  Many folks I've talked to are focusing solely on 57 days, as the news reports make it sound like if you get cyclospora, you might as well camp out in your bathroom for a couple months.  Perhaps the IDPH and media reports could mention that trimethoprim/sulfamethoxazole (bactrim) is a readily available and effective therapy? This might reduce the panic.

Dan made a radio appearance a few days ago to discuss the outbreak - you can read the transcript here. Interestingly, the segment mentioned that prior to this outbreak there were only 10 reported cases of cyclospora over past 20 years in Iowa.

"Nightmare" on Hospital Street

Not sure how we missed last week's JAMA medical news piece featuring our very own co-blogger Dan, but I suspect we might have been distracted by something pretty terrible. The article highlights the rise of carbepenem (CRE) and 3rd-generation cephalosporin-resistant Klebsiella pneumonia strains originally described in ICHE by Braykov et al. The CDC's Arjun Srinivasan emphasized that these strains are almost exclusively hospital-associated and now is the time for hospitals to implement the latest CRE recommendations from the CDC 2012 toolkit.

Dan "emphasized the importance of infection control basics such as ensuring a high rate of hand hygiene adherence among staff and making sure that surfaces and equipment are properly disinfected."  And said "If you don't shore up those things, screening [for CRE] isn't going to help."

I'll just paste in my favorite section: "An additional problem is the piecemeal approach to tracking these infections. Only 6 states require facilities to report CRE cases. “We need a more coordinated response,” Diekema said. He explained that the CDC is doing as much as it can with the resources it has, but underfunding of public health at the national and state levels makes it difficult to mount a more coordinated national effort to contain the spread of these infections. More research is also needed on the best strategies for environmental disinfection, ensuring adherence to hand hygiene and other measures that would prevent the spread of health care–acquired infections."

CRE isn't just a nightmare, it's a recurring nightmare. And just like the nine Nightmare on Elm Street films, it'll get worse over time. Especially if we continue with the current "piecemeal approach" prevention plan.

Source: Bridget Kuehn, JAMA 4/27/2013
Image source: wikipedia

Using QxMD's READ iOS? click here

The Good, the Bad, and the Ugly

The good Dr. Diekema stopped by Dartmouth-Hitchcock last week to deliver medical grand rounds. He provided a wonderful update on infection prevention. You can click on the screen shot to the right or the link below to view a video of the presentation, which includes his full slide deck. Enjoy!

Source: Dartmouth-Hitchcock Grand Rounds 1/25/2013