O Canada!

We've blogged many times about the problems associated with contact precautions, and recently we've begun to talk about scaling back on the infection control intervention that was touted as the be-all and end-all for the last two decades. Well, the Canadians are actually doing it! In this article from yesterday's Hamilton Spectator, we learn that many hospitals in Canada are no longer isolating patients with VRE, a pathogen described as "big and dumb." The head of infection control at Toronto's University Health Network says: “We think we can improve patient safety by actually stopping those specific VRE control measures.”

Are you up to your neck in chlorhexidine? Good!

When I have a little downtime, I like to think of new things to coat with chlorhexidine. If my colleagues and family members aren’t interested, I sometimes debate empty chairs about the merits of chlorhexidine. But regular readers already know how much we love chlorhexidine (despite my being well aware that this love could be fleeting).

As chlorhexidine (CHG) bathing becomes commonplace for ICU patients, it becomes increasingly important to understand exactly what we’re doing, and how we ought to do it. How long does CHG retain activity after a daily application? How much reduction in skin flora can be demonstrated? Are there commonly missed body sites that could lessen the impact of the intervention?

Mary Hayden’s group has a study in this month’s ICHE that begins to address some of these questions. Using a colorimetric indicator, they measured CHG concentrations at several time points between daily CHG application (using CHG cloths*, with no rinse). They found that CHG was usually detectable on the skin for the entire 24 hour period between bathing, but that concentrations dropped over time, with microbial counts inversely associated with CHG concentrations. As the figure below shows, the microbial density at inguinal sites was lower for CHG than either soap-and-water or non-medicated cloths (as might be expected).

Interestingly, the neck region was found to have lower CHG concentrations and higher colony counts, and upon direct observation was noted to receive less thorough cleansing. This could be important, particularly given its close proximity to tracheal/endotracheal tubes and central line insertion sites, and given that it is a body site frequently touched by care givers (while changing dressings, auscultating carotids, measuring CVP, etc., etc.).

*the COI statement points out that Sage, maker of CHG cloths, funded the MIC testing in this study, though the rest of the study was funded by CDC and NAIAD.

Dr. Ian Smith, 1922-2012

Farewell to Dr. Ian Maclean Smith, who died earlier this week in Iowa City. Dr. Smith was the founder and first director of the Division of Infectious Diseases at the University of Iowa, and was a faculty member here for over 40 years. He accomplished a great deal during his long career, some of which is summarized in this obituary. He retired the year I arrived at Iowa for ID fellowship training, so I only knew him as an emeritus professor and an occasional guide to the early Staphylococcus aureus literature. A few years ago, as I prepared a talk on the epidemiology of invasive S. aureus disease, I asked him for early (pre-antibiotic era) descriptions of the natural history of untreated S. aureus bacteremia. Shortly thereafter he showed up in my office with a bound volume of Lancet issues from 1960. The table below is from Ian’s 1960 publication in this volume, describing 338 cases of S. aureus bacteremia from 1936-1955, a time period that straddled the introduction of effective antimicrobials (pre-antibiotic era mortality was 90%).

While I was looking for an earlier photo of Ian, I also ran across an article from the Kingsport, Tennessee Daily News in April 1977 announcing that Ian had published two articles in the journal Geriatrics (yes, he was also a geriatrician). I had forgotten that his career at Iowa was interrupted by a stint at East Tennessee State University, a medical school he helped to establish and for which he was Chair of the Department of Medicine for two years. I was also pleased to see that the local papers saw fit to announce whenever faculty members published peer-reviewed papers. I’ll have to call our local Iowa City paper tomorrow morning...

Thanks, Ian, for your contributions to our field.

The menace of antibiotics

Need another reason to be concerned about antibiotic overuse? Marty Blaser’s group just published a study in Nature about the impact of subtherapeutic antibiotics on the gut microbiome, metabolism and body composition of mice. Short version: antibiotics altered a myriad of things, including the gut microbiome, levels of metabolic hormones, and hepatic regulation of lipids. The end result? A fatter mouse.

We’ve known for some time that antibiotics in low doses promote the growth of animals, though it isn’t clear exactly how that works. These findings shed light on some potential mechanisms for weight gain associated with antibiotic exposure, and may have implications for the ongoing obesity epidemic.

Finally, another plug for IDWeek! I’m happy to point out that the senior author of this paper (Dr. Blaser) will be delivering a keynote address during the opening plenary, appropriately titled, “The Menace of Antibiotics”.

Photo credit: Wikipedia commons

Back from Canada

I recently returned from our annual trip to rural Quebec, a refreshing break from everything (including the internets!). Eli’s post below, about resource-intensive approaches to infection prevention that seem so attractive compared with the hard work of basic hand hygiene, reminded me of a conversation I had over dinner with a Canadian family friend. He asked for details about the current political debate over Medicare, and I explained how one side is interested in restructuring the program from a defined benefit plan to a defined contribution plan, thereby shifting the risk of future increased health costs from the government to the individual.

“What happens when you need care that you can’t afford?” he asked. I pointed out that medical illness and the associated costs were a common cause of personal bankruptcy in the United States. He sat in stunned silence for a few moments before ending our discussion with, “Well, that’s barbaric.”

The Rise of the MIC: Microbiological Industrial Complex

Mike "Alexander" Edmond

Note: This is the post I wanted to write regarding the NIH Clinical Center KPC outbreak last week until I noticed the posts and comments blaming the front line infection prevention staff.

"...we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex (MIC). The potential for the disastrous rise of misplaced power exists and will persist....As we peer into society's future, we-you and I, and our government-must avoid the impulse to live only for today, plundering, for our own ease and convenience, the precious resources of tomorrow. We cannot mortgage the material assets of our grandchildren without risking the loss also of their political and spiritual heritage." - President Eisenhower's Farewell Address January 17, 1961

In microbiology and clinical medicine, the MIC is the "lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism after overnight incubation."  I think it's time to recognize a new definition for MIC: the Microbiological Industrial Complex. The MIC encompasses the industry, associated lobbying efforts and government agencies that most benefit from the adoption of expensive and unproven testing and treatment. The MIC has had a tremendous impact on infection prevention practice through economic forces pushing for MRSA active surveillance mandates and perhaps mandatory flu vaccinations of health care workers. This MIC leads to the utilization of expensive (and largely unproven) interventions at great cost both economically and to the well-being of patients.  The more we spend on expensive sequencing, the less we can spend on actual prevention. Hand hygiene might not be sexy, but it does more to prevent the spread of resistant infections than any PCR test.

The latest evidence of the insidious rise of the MIC is the initial discussion surrounding the NIH Clinical Center KPC outbreak. So far, the only paper describing the outbreak covered the miracle of whole-genome sequencing and how it helped halt the outbreak, which it most certainly did not. The outbreak was halted using a grab bag of unproven and expensive interventions including the hiring of 9 hand hygiene "police" that monitored infection control practice 24-7.  Even NIH's Henry Masur speaking today on the Diane Rehm show said that sequencing "didn't conclusively prove" (what caused the outbreak).  Both he and Jule Segre suggested they only stepped up their infection control efforts because of the whole genome sequencing evidence, which is almost certainly not true. They would have used infection control escalation even without expensive testing. (listen to the Diane Rehm show segment here)

To understand the power of the MIC, you don't have to look further than a recent MSNBC report, which noted that the NIH sequencing cost $40,000 and suggested that this technique could spawn a $1 billion industry in the US alone. In discussing the whole genome technique, Dr. Segre was noted to say "When you have patients in your ICU who just paid $100,000 for an organ transplant,"...spending a few thousand dollars to protect them from an outbreak of deadly bacterial infections "doesn't seem like too much to ask."

It seems to me that since there is no evidence that whole genome identified the source of transmission here or elsewhere and even if it did it wouldn't have altered the course of the outbreak, we might better spend our infection control research and clinical dollars elsewhere.  Unfortunately, the MIC has more money and more NIH backing. The NIH has a National Human Genome Research Institute but it doesn't have a "National Infection Prevention Institute", for example.

Almost a year ago, Mike peered through his crystal ball and accurately predicted the future of KPC prevention in the US.  The NIH outbreak and report starts the countdown, and much like MRSA before it, the prevention efforts will be focused on expensive DNA surveillance efforts backed by large industry lobbying efforts and not investments in the research and expansion of basic and simple infection control efforts. It is easy to blame the healthcare worker for not washing their hands and look for a quick scientific panacea (DNA). Sadly, given that there have been only four high-quality hand hygiene improvement studies since 1980, we haven't provided clinicians with the proven tools to improve hand hygiene. If we continue to bow to the pressure of the MIC and avoid the harder tasks of infection prevention, we will be squandering our precious resources of tomorrow (antibiotics), as Eisenhower warned 50 years ago.

Further Reading:
(1) Maryn McKenna: The ‘NIH Superbug’: This Is Happening Every Day
(2) Ed Yong:  Genome detectives unravel spread of stealthy bacteria in a hospital
(3) Dr. Judy Stone: The NIH Superbug Story-A Missing Piece
(4) Mike the Mad Biologist: Some thoughts on the CRE Superbugs

Image source: wikimedia commons

Not a failure, a lesson. The NIH KPC Outbreak

Mike posted about this yesterday and I'm sure we'll have more posts concerning the deadly KPC outbreak that occurred last year at the NIH Clinical Center. Since the whole report is behind a paywall (why is that??), I thought I'd describe the interventions taken to control the outbreak and also let you peruse the description of the 18 cases and 11 deaths (See table below).

The kitchen sink: the problem
and the current solution

Infection control measures used:
1) Index patient placed on enhanced contact isolation on admission.
2) All ICU patients during the outbreak were placed on universal enhanced contact precautions during their entire stay
3) A wall was built in the ICU, so that all KPC+ patients could be placed in a new six-bed unit
4) Infection control compliance monitors were hired (peak use was 9 monitors) who ensured that all healthcare workers entering the rooms practiced enhanced contact precautions and hand hygiene. Suboptimal monitors were fired
5) A private firm was hired to decontaminate the ICU and all KPC+ patient rooms using hydrogen peroxide vapor
6) Staff were cohorted so that staff did not care for both KPC+ and KPC negative patients
7) When the KPC was found in a sink, they tore out the plumbing
8) Active surveillance culturing using rectal and throat swabs was utilized

What an amazing effort by Tara Palmore and others at NIH. Why did it take so long to control the outbreak? It's not their fault. I was in a similar situation with an acinetobacter outbreak in 2002. What I faced in 2002 and what Dr. Palmore faced last year is that there is almost no science behind infection prevention interventions. We literally don't know what works or where in works. What this outbreak demonstrates is what happens when you make little investment in infection control science in decades. We don't know how to prevent these outbreaks, so we throw the kitchen sink (literally in this case) at them hoping something works.

Not every hospital can afford to undertake all of the expensive construction and staffing interventions that the NIH did, especially since it isn't clear what works and what doesn't. Unless we make serious efforts in understanding the science behind hand hygiene compliance improvement, optimal use of contact isolation, environmental cleaning and other "unstudied" areas, this scene will continue to be repeated over and over again. These outbreaks are happening every day in the US and patients are dying (see below). We need science in infection prevention just as much as we need novel antibiotics.  The lesson needs to be that we fund CDC and other agencies to direct the infection prevention studies necessary to prevent and terminate these terrible outbreaks.

The wrong lesson is to blame frontline infection prevention staff for fighting an outbreak with one hand behind their back and not being successful. We need to stop blaming clinicians and start funding the science to assist our infection prevention efforts.  If we won't have novel antibiotics for 10-20 years, we better start getting serious about infection prevention.