Awaiting the Supreme Whatever

Will they overturn the Affordable Care Act, or just part of it? How will it affect us as patients and providers? How will it impact public health and prevention efforts (the Prevention Fund is already vulnerable, as we know)? Whatever happens, we have a lot of things to fix, because clearly we’re doing it wrong. Maybe we aren’t screening enough people for MDROs.

Source: OECD

Detecting and preventing carbapenem-resistant Enterobacteriaceae (CRE)

Late last week, the CDC issued new guidance for control of CRE. You can read my 2009 post for thoughts on their initial guidance. This update expands on that guidance, providing tailored recommendations for different settings, ranging from regions where no CRE have been reported to those in which CRE are common. The guidance also emphasizes regional control and the role of long term care (and “long term acute care”) in the epidemiology of CRE.

I think the new guidance is on the mark, and should be helpful as we struggle with how to respond to these bad bugs. As was the case back in 2009, my main concern relates to the screening recommendations. Not all CRE are created equal, and the test methods available to most laboratories are not good at differentiating among the really nasty (e.g. KPC- and NDM-producers) and the moderately nasty (e.g. chromosomal cephalosporinase + porin protein mutation). The former have much greater outbreak and local-regional spread potential, which is why the modified Hodge Test (MHT) has been used to single them out. But the MHT is not always easy to interpret, can have falsely positive and negative results, and seems to perform especially poorly in detecting certain carbapenemases (e.g. NDM). The CLSI has issued lower MIC breakpoints to better detect CRE, but these breakpoints are (appropriately) designed to guide therapy for individual patients, not to provide detailed information about resistance mechanisms for infection prevention or public health purposes. Lower breakpoints means more CRE detected, most of which do not carry mobile resistance elements like KPC and NDM. Do we respond to them in the same way (they are still resistant, after all….)?

I favor making CRE (at least those due to carbapenemases) reportable, as a couple states have done, along with periodic regional prevalence surveys to help facilities and public health departments understand local and regional epidemiology of CRE (and to help detect emerging new resistance mechanisms). These surveys would need to rely on culture, with referral of all isolates that have a CRE phenotype to state or regional labs that can do the molecular work to determine the underlying mechanism(s).

Friday feces blogging (part 5)

A year or so ago, I bought a new external hard drive for my computer (see photo). I marveled at its storage capacity--1 terabyte! That just seemed to be a huge amount of information. So I almost fell off the exercise bike today when I read a statistic in this month's issue of The Atlantic (free full text here) on the data capacity of human feces. According to Larry Smarr, a computer scientist who views the human body as a ginormous database:

"There are about 100 billion bacteria per gram (of stool). Each bacterium has DNA whose length is typically one to 10 megabases--call it 1 million bytes of information. This means human stool has a data capacity of 100,000 terabytes of information stored per gram."

Now to bring all of this home, you should know that I use 30 gm of stool for the fecal transplant procedure. So if my math is correct, I am instilling 3 million terabytes (or 3 exabytes) of information.That is nothing short of amazing!

Bundle fumble?

This week's JAMA has an excellent review (free full text here) on the prevention of ventilator-associated pneumonia (VAP). Specifically, the authors offer a critical assessment of the widely utilized IHI VAP bundle. They offer two important conclusions:

• "The ability of the bundle to prevent VAP has not been definitively established with high quality studies."
• "No large randomized study has demonstrated that reducing VAP using any strategy, including the IHI bundle, is associated with improvements in clinical outcomes."

Here's another example where an intervention has been touted as gospel, pushed hard and implemented broadly without the evidence necessary for a hardline approach.

Photo: OregonLive

NDM-1's knocking at the door, Let 'Em In

This weeks MMWR has a report from Len Mermel's group of a patient initially hospitalized in Viet Nam. Upon readmission earlier this year to a hospital in Rhode Island she had a Klebsiella pneumoniae containing NDM-1 recovered from a urine specimen. The isolate was only susceptible to tigecycline, and the polymyxins.

Extensive surveillance testing was completed and one patient admitted to the same hematology-oncology unit grew an NDM-1 containing K. pneumoniae isolate from a rectal surveillance swab.  This isolate was indistinguishable from the index patient's isolates by PFGE, confirming patient-to-patient transmission.

Europe boosts antibacterial discovery funding from zero to a wee bit more than zero

This week's Lancet has a report on a new European public-private partnership called the Innovative Medicine's Initiative (IMI). The IMI is funded through €1 billion donations from both the EU and European Federation of Pharmaceutical Industries and Associations to stimulate innovation in challenging areas. The goal is to fund antimicrobial drug discovery to the tune of €600 million ($761 million) by 2020, or roughly $100 million/year.

Perhaps this is finally the chance to move beyond the two new classes of antibacterials developed in the past 30 years. Should we be excited? Sure, $100 million/year seems like a lot of money, but this should be seen as a necessary first step.

First, this $100 million has many targets including MRSA or Acinetobacter and if you think about the way NIH defines antimicrobial resistance, most might go to non-bacterial pathogens. Second, when you compare it to the funding spent confronting a single viral pathogen, HIV, it quickly becomes clear that more is needed. For example, NIH spent $3.075 billion on HIV/AIDs research in FY12 and expects to spend the same amount in FY13. Thus, if we assume flat budgets, that would be roughly $23 billion by 2020. $23 billion is 30 times $761 million. Exactly. Well, not exactly, but you get my point.

image source: http://prospect.rsc.org/blogs/cw/2010/02/26/chemistry-worlds-weekly-round-up-of-money-and-molecules-107/

Remember primum non nocere? Ok, then stay home

A new study in the Archives of Internal Medicine reports the results of a survey of 150 Internal Medicine residents from 20 residency programs on presenteeism. 51% reported they had worked at least once in the last year with flulike symptoms, and 16% reported working at least three times. The two top reasons cited for working while ill were not wanting to force colleagues to cover and feeling responsible for patient care.

Tomorrow I give my annual infection prevention talk to all new incoming residents at our medical center. And again I'll make a plea for the young doctors to stay home if they are ill. But when will SHEA and other organizations begin to tackle this issue? It's much easier and cheaper for hospitals to mandate influenza vaccination than reduce presenteeism. While mandating flu vaccine allows hospitals to look tough, reducing presenteeism is likely to be more effective at protecting patients.  

Photo: Zazzle