Ebola: Doc from Oklahoma City Calms the State of Texas

Many of you might not know that Kent Sepkowitz, while living and practicing in NYC, hails from the great state of Oklahoma. So when Stephen Colbert went in search of an infection control expert with Red-River roots, he couldn't do much better than our esteemed colleague, just a taxi ride away. If you're still left wanting more after watching this video, head on over to NPR to hear one of the better discussions of Ebola with Kent and Scott Simon from Weekend Edition. 

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!

CDI? Think PPI

Following up on last years MMWR that reported that "nearly 75% of all Clostridium difficile infections (CDI) related to U.S. health care have their onset outside of hospitals", CDC researchers have released a new study in JAMA Internal Medicine looking specifically at the epidemiology of community-associated CDI. The study used data from the Emerging Infections Program, which began to actively collect CDI data in 10 states starting in 2009. This report uses data from 984 patients collected over 29 months with true community-onset CDI, as they excluded community-onset, healthcare facility associated infections.

Somewhat surprisingly, 36% of patients had not received antibiotics and 18% had no outpatient health care exposure. Not surprisingly, 31% of those who had not been exposed to antibiotics had been exposed to PPIs.  I highlighted the risk of CDI from PPIs in my ICPIC talk last month when I discussed this meta-analysis by Kwok and colleagues. In this CDC study, those patients lacking significant outpatient healthcare exposure were also more likely to be exposed to infants and household members with active outpatient healthcare exposure suggesting a potential route of transmission. I agree with the authors primary conclusion that a reduction of outpatient PPI use may be necessary to reduce the risk of CDI. As Mike' pointed out four years ago, PPIs are also associated with HAP, VAP, and SBP, so there are many reasons to be concerned about PPIs.

There is an excellent accompanying editorial by some guy named Kent Sepkowitz, who discusses the "PPI-zation" of the US and the difficulties facing any public health initiative targeting PPIs. For one, PPIs are the third most utilized drug in the US and they are addictive since discontinuation is associated with withdrawal symptoms.  For another, unlike antibiotics, PPIs are widely available over the counter and supported by huge advertising campaigns. Looks like PPIs are here to stay...

Intrigued by the plot of Kent Sepkowitz’ perspective piece on antibiotic stewardship in the NEJM

This is a guest-authored piece by Dr. Tom Gottlieb (Senior Specialist in Microbiology and Infectious Diseases, Concord Hospital, New South Wales, Australia), wherein he discusses Kent Sepkowitz's latest commentary in the NEJM.

This is writ in the genre of a thriller in which a new generation of ID physician villains (the previous heroic ID generation’s illegitimate offspring, it seems ) abound as ‘fervent’ ‘chastisers of antibiotic overuse and abuse’. These ‘self-pitying’, ‘inept’, ‘feckless’ ‘prohibitionists’, ‘gnawed with regret’, indeed ‘deranged’, threaten to undermine and disenfranchise the orderly world of antibiotic prescribing, by seeking to banish miracle antibiotics forever from the world. Indeed their quest, (in cahoots with the loonies of the anti-vaccination lobby), is so dangerous, it is spelt out in the more sophisticated French; “an idée fixe”. These antibiotic nihilists cannot appreciate the true contribution antibiotic chemotherapy has made to individual patient care and also to the global well being of humanity.

Now I too enjoy debunking zealotry, and would not deny that there is plenty about antibiotic stewardship that is worth challenging in a balanced discourse. And stewardship, (or is it shepherd-ship?) can be clearly problematic. As ID physicians, we are frequently left in a schizoid situation where, as on one hand we attempt to control unnecessary use, on the other, in individual care we often contribute to broad-spectrum prescribing. Moreover some clever contrarianism never goes astray. But Sepkowitz’ pendulum swings beyond healthy scepticism, past contrarianism, to something akin to denialism.

Damn it, I too need to reach for the French dictionary. Un agent provocateur? Peut-être, saboteur? Because there is significant damage caused when worthwhile attempts, not as suggested by Sepkowitz to deny antibiotics for patients, but to preserve antibiotics into an uncertain future, are derided by ID doyens. But without him providing us with any cogent examples of groups or policies that would support the existence of these villanous ‘antibiotic prohibitionists’. And the very simplistic, polemical, good versus evil like vision he paints, creates a disservice to the antibiotic debate. (Or is it that for the sake of a good argument, as Oscar Wilde wrote, Sepkowitz feels that “in matters of great importance, style, not sincerity is the vital thing”)

I agree with Sepkowitz that “just in case” prescribing, often saves the day in settings of uncertainty. But one of the banes of our clinical existence is ‘just in case’ prolonged orthopedic prophylaxis, ‘just in case’ ceftriaxone in heart failure, ‘just in case’ stat gentamicin dose pre catheter removal, just in case treatment in case confusion is caused by a urine infection, or a few more days of treatment ‘just in case’, etc..; situations in which antibiotics are used to treat the prescribers’ anxieties rather than the patient’s condition.

I find Sepkowitz’s piece in the NEJM more a diatribe than a commentary. But it is a very useful piece too. It is a wake-up call that if we fail to convince other ID physicians regarding the merits of prudent antibiotic use, we have a long way to go to change attitudes amongst medical peers or in the community.

Image: Nicolas Poussin's Adoration of the Golden Calf. "The Golden calf of Stewardship" paraded in front of idolatrous ID physicians?

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.

Learned Helplessness and Hand Hygiene

MSKCC's Kent Sepkowitz has a recent commentary in Lancet ID on hand hygiene.  He thinks that modern hospitals are too clean to benefit from hand-hygiene improvement efforts (I guess he hasn't read this paper). He concludes:

"The time has come for the infection control community to move on; please, no more cheerleading louder and harder to get thousands of people to improve their hygiene. We have to accept that our age-old dream of solving a complex problem cheaply and simply has failed. Instead, we must reacquaint ourselves with that lonely feeling familiar to clinicians when they realize a case is much more difficult than it appeared at first glance. In other words, we should embrace the intellectual audacity of our beloved Semmelweis but let go of his how-to manual. As he might tell us (loudly): an ineffective remedy is much worse than no remedy at all."

Is he right?  I don't think so.  There have been only 4 hand-hygiene intervention studies in the past few decades of high enough quality to warrant inclusion in the 2011 Cochrane Review. I say before we throw in the towel, bury our collective heads in the sand and go all Eeyore, we should probably do a few more than 4 good studies.  I also suspect that if we could really figure out why MRSA has declined in recent years, it would come down to hand hygiene improvements and not some expensive PCR.

Waiting for the Flu...

"Shouldn’t we all be dead by now?" is the first question that Kent Sepkowitz, card-carrying hospital epidemiologist, asks in his latest article in Newsweek.  He goes on to ponder why it's almost February and there's so little influenza activity and suggests that nothing we have done to prepare has made any difference including influenza vaccination and alcohol hand rub .  He hints that perhaps La Nina or climate could be a possibility.

He concludes by saying: "In fact, what we are seeing here is the dark secret of medicine and public health: the fact that we usually have no clue why something, good or bad, is happening...(and) should accept that we are mere spectators to an inscrutable alliance of virus, animal, and climate, a longstanding collaboration that we cannot, as yet, influence — though getting that flu shot might help."

Kent Sepkowitz, Newsweek/Daily Beast 1/23/2012