Watch this video! It will change your life and the future of the world!

The overselling of science can be pretty hilarious when described by John Oliver, yet it infects not just the media but also scientific journals and professional conferences. One of the aims of this blog has always been to question the latest fad sweeping infection prevention nation; see Dan's recent post on ADI for CDI or my talk on public reporting of HAIs. In addition to highlighting the bit at the end of the video that notes the 70% increase in authority that descends upon those wearing a white coat, I've pulled out these quotes for you to ponder:

"Just because a study is industry funded or its sample size was small or it was done on mice doesn't mean it's automatically flawed, but it is something the media reporting on it should probably tell you about." - John Oliver

"I think the way to live your life is to find the study that sounds best to you and you go with that" - Al Roker

Evidence-based infection prevention: A modest proposal

This is a special guest post by David Hartley, PhD who is a Research Associate Professor in the department of Microbiology and Immunology at the Georgetown University Medical Center.

I don't know if there are dedicated courses in schools of medicine and nursing in the US devoted specifically to hospital infection control and prevention, but if there are, I haven't found them. There are lots of training courses offered by trade societies, and many of these are great at conveying procedure, technique, and rationale, but I'm thinking about academic, didactic courses presenting a comprehensive picture of what is known, how it is known, and emerging ideas about infection control and prevention. Any science-based course should expose the learner to the continuum of theory, evidence, and practice. I think it could be done in a semester.

How best to approach such a course needs to be discussed and worked out, but one might, for example, begin with a survey of what we know about what people are commonly colonized and infected with, and how they got that way. This would entail examination of aerosol, alimentary, percutaneous, and other infectious pathways as appropriate, focusing upon important pathogens of concern in healthcare facilities. It could then go on to examine microbial life histories along each route of infection, and how common hospital practices act synergistically or antagonistically with each such route. Host response to infection would be important to cover, and a quantitative epidemiological component should also be included. To tie everything together, learners could undertake a final project assessing what current infection prevention practices are evidence-based and which aren't, and what evidence might be useful for better informing infection control practice. Such a course might be entitled Infection Control and Prevention: From Science to Practice. If done well, the course could help to train learners to think about infection within the context of a coherent, interconnected, evidence-based picture.

By and large, it seems like such an expansive, theoretical picture of hospital infection control and prevention is lacking at present. There are mathematical and computer models of varying complexity and realism that together have led to insights, though how to generalize and apply these is sometimes unclear to preventionists. There are also rules and guidelines, though some (many?) are not as well studied as one might expect (e.g., handwashing and contact precautions). There are increasing numbers of studies suggesting that this intervention works here and that intervention works there, but understanding how all this knowledge fits together to inform thinking and practice, in a truly robust way, remains elusive. A systems approach to both teaching and thinking about infection prevention may prepare the next generation of researchers and clinicians to think more holistically and progressively about infection in healthcare environments.

Six dangerous words

There's an interesting essay in JAMA this week entitled EBM's Six Dangerous Words. In it, Scott Braithwaite argues that physicians should banish the phrase "there is no evidence to suggest that..." He gives as an example: there is no evidence to suggest that looking both ways before crossing a street compared to not looking both ways reduces pedestrian fatalities. While that's technically true, as he puts it, such statements presume "a definition of evidence that requires formal hypothesis testing in an adequately powered study." It makes objective certainty the be-all and end-all, and "is ambiguous while seeming precise." I have heard hospital epidemiologists state that there is no evidence to suggest that white coats can transmit infections in the healthcare setting. Ok, but sometimes the common sense of the average Joe trumps the best the medical literature has to offer. Or so it should...

The Fact-Filled Infection Control Guideline - A New Year's Wish

I'm not sure what about the above tweet got me to thinking about infection control. Before hopping on the twitter this morning, I was happily building Lego scenes with my kids and thinking about this afternoon's Indiana-Iowa basketball game (Dan - thanks for the tickets!). In infection control, there isn't a direct equivalent to the "mindless symmetry" in political journalism mentioned by Jay Rosen, which treats talking points on both sides of the aisle as equivalent without considering the facts. However, there is a similar "mindless" glossing-over of the facts by public health and society guideline committee members that appears in every HAI-guideline - recommendations based on minimal data. Instead, many (can I suggest most) of the recommendations in HAI guidelines are based on uncontrolled before-after quasi-experimental studies, expert opinion and perpetuated dogma. 

Mike pointed out a few days ago what can happen when a medical specialty, such as hospital epidemiology, recommends policies like mandatory masks for unvaccinated healthcare workers during influenza season, which are based on minimal data. I'm not even going to mention mandatory influenza vaccination for healthcare workers... But what about other claims in guidelines and by policy makers? Do we have enough evidence to support many of our interventions including most stewardship recommendations? And what about the claim that MDR-Gram negative outbreaks could be controlled if not for the unwillful healthcare worker? 

What happens when we perpetuate opinion and dogma? Although 270-page hand hygiene guidelines may make us feel good, I'm worried that they prevent us from identifying areas where we need research (hand hygiene improvement interventions, anyone?) and lead us to spending days and weeks implementing ineffective or even harmful interventions. Does anyone stop to think how these fact-challenged guidelines might be hurting our patients and eroding our reputations? It seems to me that we shouldn't be spending our political capital implementing "expert opinion" since it will hinder our efforts when we actually are armed with evidence-based interventions. Imagine that day!

So my wish for the new year is that guideline committees only include recommendations based on evidence, not opinion or dogma, no matter how hard politically that is for them in the short term. In the long term, if we insist on evidence, we might actually get evidence - someone might notice and start funding infection prevention studies. (e.g. What do you mean we don't know how to halt the spread of MDR-GNRs??) And if our guidelines are shorter and filled with evidence-based recommendations, clinicians in the field will be able to focus on interventions that actually work and not spend their valuable time on willy-nilly dogma-of-the-day recommendations that harm our reputations or worse, our patients. 

Evidence-based Backlash: The Xigris eXample

Rich Savel, has a wonderful editorial in this month's issue of the American Journal of Critical Care (AJCC) discussing the importance and dangers of evidence-based medicine as currently practiced. He and co-author Cindy Munro use the rise and fall of Drotrecogin Alfa (Xigris, activated protein C) as an example for what can go wrong and why.

Rich Savel in the center

Their key conclusions:

1) "Though the results of a single, large RCT are important, they clearly are not sufficient for future agents to be rapidly integrated into national guidelines or consensus statements."

2) "Another important lesson is that pharmaceutical companies should stay as far removed as possible from development of guidelines promulgated by national medical societies. One of the most important things such a society has is its reputation, which it must be careful not to tarnish. Although this can often be a great challenge, it has become quite clear from the controversies surrounding APC that the relationship between pharmaceutical corporations on the one hand and academia and national medical societies on the other should be kept distinct and transparent."

3) and finally - “... the single most important lesson from the rise and fall of APC is that we should maintain skepticism: maintain it until the trial can be reproduced; maintain it in the face of trusted medical societies integrating recommendations for agents before sufficient evidence is presented; and maintain it until all potential conflicts of interest have been shared. EBM is not merely one way to practice; it is the only way. In addition to understanding all of the dynamic complexities and nuances of EBM, we must develop a healthy skepticism toward new research results and apply that approach liberally as the scientific method does its important job of confirming the validity of those results."

Full Disclosure: Rich and I were residents at NYH-Cornell back in the 1990s and we were also co-Assistant Chief Residents at Memorial Sloan Kettering under Kent Sepkowitz. Rich has gone on to great things as co-editor of the AJCC and medical directorship of the surgical intensive care unit at Montefiore Medical Center, Albert Einstein College of Medicine in NYC. Rich is also the editor and founder of the SCCM iCritical Care Podcast - which rocks.