More troubles for Berwick?

Much of the recent criticism aimed at Don Berwick, the new CMS Administrator, is, in my opinion, unfair and politically motivated. Other criticism is legitimate, as some in the quality and infection prevention communities have disagreed with his willingness to vigorously pursue some strategies that lack strong evidence. This was discussed in a blog posting a few months ago by Bob Wachter. Now there's a new issue emerging. Sen. Chuck Grassley has requested that Berwick disclose the funding of the non-profit he founded, the Institute for Healthcare Improvement. According to IHI's 2008 form 990, which can be viewed at the Guidestar website, Berwick's reportable compensation was $2.3 million in 2008. Regardless of the motivation behind Grassley's information request, whether Berwick has conflicts of interest is a legitimate question.

Addendum (8/1/10, 9:50 AM):  Click here for more.

CDC's recommendations for flu vaccine

CDC has just released its annual recommendations for influenza vaccination for the upcoming flu season. You can view the document here. There are very few new recommendations. The biggest change is that vaccination is now recommended for all persons 6 months of age and older. The publication notes the availability of high dose vaccine for persons 65 years and over but offers no recommendations regarding its use.

My surgeon has S. aureus!

Don't panic! Just based on probability a surgeon would have a 30% chance of being colonized with MSSA and perhaps a 1% chance of being colonized with MRSA. Researchers at NYU Hospital for Joint Diseases recently screened a total of 135 orthopedic surgeons for MRSA and MSSA nasal colonization. In the 74 attendings, 2.7% were MRSA+ and 23.3% were MSSA+. The story was a bit more interesting in the 61 residents with 59% MSSA+ and none MRSA colonized. Overall, 36% were MSSA+ and 1.5% were MRSA+, which is about what we would have guessed before the study.

These results are similar to Cecilia Johnston's report of healthcare worker colonization at Johns Hopkins a few years ago. She reported 28% S. aureus colonization (95% confidence interval [CI], 22%‐34%) and 2% MRSA colonization (95% CI, 0.04%‐4.0%). I pasted in Cecilia's results to highlight the fact that she calculated confidence intervals for each proportion. The NYU researchers were surprised by the high proportion of residents with MSSA colonization. Sure, the level was high, but if they would have calculated the 95% CI, which was 46%-71%, they might have been less excited.

It's possible that the long hours spent in direct patient care might be risk factors for MSSA colonization, as would frequently performing dressing changes, but these would not be unique to ortho residents. Perhaps they should repeat the study in the same residents at a later point to determine what proportion is transient vs persistent colonization. Of course, it would be nice to repeat the study in other cohorts of ortho residents and ortho nurses.

They also reported that patients screened prior to THR, TKR and major spine surgery at their hospital had 2% MRSA and only 18% MSSA colonization. It would have been nice to read more information about these patients, such as recent antibiotic exposure.

Schwarzkopf et al. in Journal of Bone and Joint Surgery (America): PubMed or JBJS
Johnston et al. in December 2007 ICHE
Easy confidence interval for proportion calculator: link

Is PJP a nosocomial infection?

There's a paper in the August 1 issue of Clinical Infectious Diseases of interest to the infection prevention community. In this French study, investigators sought to determine whether Pneumocystis jirovecii could be detected in the air near 19 patients who had documented infection with the organism. The proportion of samples yielding Pneumocystis significantly decreased with distance from the patient. Of samples obtained 1 m from the patient, 79% were positive; 69% were positive at a distance of 3 m from the patient; 42% at 5 m (at the entrance to the patient room); and 33% were positive at 8 m (in the corridor outside the patient room). The authors note that existing animal models have documented host-to-host transmission.

So the real question is whether current infection control guidelines are robust enough. CDC recommends not placing another immunocompromised patient in the same room as a patient with PJP (p. 108 of this document). Most HIV patients with PJP are initially placed in airborne precautions to rule out concomitant infection with M. tuberculosis. Tuberculosis can be ruled out in 1-2 days, and fortunately there were no positive samples at 5 or 8 m >1 day after the start of treatment for PCP.

My bigger concern is for transplant patients, who in many hospitals are geographically concentrated on specific units. Often these patients are able to ambulate in hallways, where they could encounter the organism outside an infected patient's room. Moreover, rooms in bone marrow transplant units are often at positive pressure, which would likely drive more organisms outside the room. I guess the good news is that we don't see many transplant patients with PJP since many receive prophylaxis for a period of time post-transplant, but it's probably an issue that we need to monitor a little more closely.

The CDC has a brand new blog

And I like it! I especially enjoyed the post by our own Phil Polgreen, which features his iScrub application. Alex Kallen also has a nice recent post on prevention of CLABSI outside the ICU, which is a topic overdue for attention.

However, I did wince when I read about this event:

“I believe in zero CLABSIs!” shouted a group of 3,400 APIC Annual Conference attendees at the conclusion of patient-safety leader Dr. Peter Pronovost’s opening session.

Why does this make me uncomfortable? It isn’t because I haven’t bought into the power of CLABSI prevention efforts—we have units whose efforts have pushed CLABSI rates to zero for months at a time, and we celebrate that. I also think that most infection preventionists (IPs) understand the difference between a rah-rah, go-get-‘em, “aspirational” BHAG on one hand, and a realistic assessment of what is preventable on the other.

The problem is that many people don’t understand this difference. Among them are fellow healthcare workers, hospital administrators, reporters, the general public, third-party payers, and malpractice attorneys. To them, 3400 infection control experts witnessing to their belief in zero CLABSIs means that every CLABSI must be preventable, and therefore that every CLABSI represents an unconscionable breach of practice. We’ve blogged before about some of the potential unintended consequences of the “zero” paradigm. Fudged definitions, antibiotic overuse, pitched battles between unit personnel and IPs over every device-associated infection, and an atmosphere of blame and punishment, just to name a few.

The fact is that not every CLABSI is preventable. Most are, but not all. Even Peter Pronovost’s hospital's ICUs, though they have wonderfully low rates, still experience CLABSIs. If we follow perfect processes of care, we should be able to prevent those infections that arise from around the catheter insertion site, and those that are introduced exogenously. But what about those arising from gut translocation of bacteria in a critically ill patient? Even the most aggressive gut decontamination regimen (which will inevitably accelerate antimicrobial resistance rates) won’t be able to prevent organisms from gaining access to the catheter in this way.

We should be able to mobilize the troops to drive CLABSI rates to their irreducible minimum without setting unachievable goals. I do admit that “getting to zero” is a catchy phrase, though, and very well-suited to campaigning for lower infection rates. The theme I proposed for our latest CLABSI prevention campaign was roundly rejected….and I still don’t understand what was so wrong with: “Zero Is Great, But One Every Few Months Is Pretty Darn Good, Too”.

Good move Maryn McKenna

We have written often on conflicts of interest. So, I've been following the recent "problems" over at ScienceBlogs.com closely. Quick story is that 2 weeks ago the editors there added a Food Frontiers blog completely funded and written by PepsiCo. I think internist PalMD said it best:

"It could be argued that since it is clearly announced that the content is PepsiCo's, that transparency is maintained, but it's not. Readers of the other 70-odd blogs at Sb expect independent content in the center column. What's more, Sb is indexed by Google News. As a news outlet, we should be held to a high standard. If the SEED management can't see what's wrong with this, this may be an insoluble problem."

PalMD left and returned to his old site as did Maryn McKenna. Many other great bloggers have left too. It must have been a difficult decision to leave the collective, but it is a good one.

PalMD's White Coat Underground (link) and PalMD's full comments (here)
McKenna's Superbug blog (link)
The Guardian's take (here)
Our COI posts (here)

MRSA: Resistance isn't futile?

"I am Locutus of Borg. Resistance is futile." - Locutus of Borg

Any science blog must eventually quote from Star Trek. Now that we've gotten that over with, you can relax. Seriously, relax. Seriously.

The Borg, like MRSA, exhibit a rapid adaptability to any situation or threat. They are perhaps the most menacing cybernetic organisms ever imagined, with all due respect to the Daleks, etc. So you can see why, when I think of MRSA, I often think of the Borg. MRSA is menacing and surely resistance to MRSA is futile. MRSA will rise forever, out of control. Well, not so fast.

A new report out in Diagnostic Microbiology and Infectious Disease by Jose Bordon, et al. report trends in MRSA counts and proportion that are resistant to non-B-lactam antibiotics during the period 1996 through 2008. The analysis included over 2 million S. aureus isolates and almost 1 million MRSA. Their main findings are (1) MRSA increased in Borg-like fashion until 2004 and (2) resistance to all tested antibiotics, except erythromycin, decreased signficantly during the 12-year period. Resistance to ciprofloxacin, clindamycin, gentamicin, tetracycline, and trim-sulfa decreased measurably. The authors claim this could be due to increasing CA-MRSA as proportion of all MRSA. I'm not sure that could explain all of the declines or that it should alter empiric therapy, as suggested by the authors. Overall, the findings seem encouraging.

DMID article by Bordon (link)
Wikipedia article on the Borg (link)