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. 

Larry

Reuters today has an article on Larry, a humanoid simulated vomiting system, which is used to analyze the effect of norovirus environmental contamination. I always like to add a picture to my blog posts, but today you'll be thankful I did not. Anyway, the synthetic vomitus used in the simulator, has a fluorescent marker that enables investigators to examine how widespread is the contamination after an episode of vomiting. Using Larry, they have found that droplets travel over 10 feet. This is important since the infecting dose of norovirus is very small, which makes it highly transmissible. As noted in the article, each droplet of vomitus has enough virus to infect over 100,000 people.

I have always wondered why anti-emetics are not available over-the-counter. If they were, quite a lot of misery could be avoided, ER visits averted, and maybe they would even provide norovirus source control by reducing environmental contamination.

Addendum (1/4/13):  NPR has added a video of Larry doing his job. It's quite impressive.

The lunacy continues

It appears that an increasing number of hospitals are requiring healthcare workers that are not vaccinated against influenza to wear masks (see a recent example here). I have yet to see any evidence to support such a policy, and I'm not even sure of the purported intent (is it to prevent infection of the unvaccinated HCW, or is it to prevent the infected HCW from transmitting to patients?).

Whatever the intent, it seems completely impractical. Wearing a mask for 8-12 hours is uncomfortable and an unnecessary distraction. I suspect it also impacts morale. So none of this makes sense to me, but neither does mandatory influenza vaccination.

Last week, the Massachusetts Nurses Association characterized the mask policy as an act of bullying. That's a strong word, but after thinking this over, I admit that I have to agree. I don't think the mask requirement has been promulgated to reduce transmission of influenza; rather, I suspect it's to punish those who don't comply with vaccination. So here we have a mandate that doesn't make sense, aimed at those who don't comply with another mandate that doesn't make sense. And the lunacy continues....

Photo:  3M

Happy Holidays from CHIP

The image above is courtesy of Stephanie Mounaud at the J. Craig Venter Institute. The fungi represented include Aspergillus nidulans (tree), Penicillium marneffei (red ornaments), and Aspergillus terreus (trunk). For more enjoyable holiday images made of fungi, check out her post here.

For a less festive take on Kingdom Fungi, see this recent Slate piece. As I used to tell the medical students when I gave my annual series of mycology lectures, “the fungi have their own Kingdom--we just live in it.”

Should we go over (to) the Cliff?

There's been a lot of talk in the US about "the cliff," specifically the fiscal cliff. Should we go over the cliff? Is the cliff just a curb?  What should we do? Panic! In response, the GOP has started pushing "Plan B," which will apparently require all Americans to receive emergency contraception if they're pregnant. This has some merit since if we no longer exist, we can't really run up the budget deficit, now can we.

Anyway, this is ostensibly an infection prevention blog, so I better get back on topic.  In the annual Christmas issue of the BMJ, investigators from the Netherlands have reported a novel method for speeding up the diagnosis of Clostridium difficile infection. The name of their novel method?  Cliff.  Just as I expected, they call or email the CDC and ask Cliff McDonald what he thinks! NO? What?

It turns out that they've trained a beagle named Cliff to diagnosis C. difficile by smell (thank goodness it's not taste). Anyone who has done an ID fellowship or even a medical internship gets pretty good at recognizing the unique small of C. diff, so we know this could work. It turns out to work pretty well. Cliff's nose detected C. difficile positive clinical samples with a sensitivity of 83% and a specificity of 98%. Not too shaggy.

Addendum: A 2007 CID study reported self-selected nurses had a sensitivity of 55% and specificity of 83% in diagnosing C. diff, while an earlier study reported that nurses had a sensitivity and specificity of 84% and 77% for predicting C. diff using factors that included odor. I would like to see Cliff dual it out with these nurses in a future trial. Daniel Uslan suggested Cliff vs "Sniff": an RCT.

"At the end of the day, the drug companies own medicine"

The title of this post is a quote by Eric Campbell of Harvard Medical School in an investigative piece in yesterday's Milwaukee Journal Sentinel. The article focuses on conflict of interest among physicians who write practice guidelines for academic societies.

Here's a summary graphic from the article:

This article is worth reading, but it's disturbing.

Trouble at the Pittsburgh VA

The Pittsburgh VA has had a recent outbreak of nosocomial legionellosis. Based upon press reports, there have been at least five confirmed cases with one death. There are also references in the media to 24 additional cases reported beginning in January of 2011 (8 of which were felt to be community onset, and 16 unknown onset—likely in the “possible nosocomial” category). CDC personnel traveled there to assist in the investigation, and full details are likely to emerge eventually. 

There is a highly charged back-story here. Reading the press reports, one immediately notices some very pointed critical comments from two internationally recognized Legionella experts. In 2006, there was an acrimonious split between the Pittsburgh VA and Victor Yu and Janet Stout (you can read their side of that story here--click through to some of the e-mails to get a flavor for just how nasty this episode was). This public dispute ended with the destruction of a massive organism bank that included thousands of Legionella strains, leading to a letter and petition being published in Clinical Infectious Diseases. And now that the Pittsburgh VA is knee-deep in Legionella without them, these two colleagues are not holding back. 

We’ve had our own history with Legionella at Iowa, and this outbreak in Pittsburgh may reiterate several important lessons we learned long ago: (1) never assume that Legionella has been eradicated from a water system, it is only suppressed to levels that cannot be detected, and will re-emerge when given the opportunity, (2) copper-silver and chlorine dioxide suppression systems work, but only if they are carefully maintained and levels of the active agent(s) are monitored (not just centrally, but also at distal sites), (3) installing a suppression system doesn’t obviate the need for regular water testing in facility that has had nosocomial cases of legionellosis, (4) there is no way to definitively determine the source of a legionellosis case if cultures are not performed on patient samples (the urinary antigen test doesn’t provide an organism for typing), and (5) all legionellosis cases that fall into the “possible nosocomial” category (onset between 2-10 days after admission) should be assumed to be nosocomial, and an appropriate investigation begun to assess for a source in the hospital water supply.