More on CLABSI validation

A new study in the American Journal of Infection Control looks at validation of publicly reported CLABSI (central line associated bloodstream infection) data in New York. To my knowledge, New York has done the most work on validation, so it's worth taking a look at this paper. The authors analyzed CLABSI data from 2007 through 2010. By year, the sensitivity of reported data varied from 68% to 74%, and for the entire time period was 71%. Of concern, there appeared to be no improvement over time, and for 2010 sensitivity for medical ICUs was only 46%. Specificity ranged from 90 to 99%. So, about 30% of CLABSIs are not reported in a state that has focused on validity. It makes you wonder how bad validity may be in states that have done little work on this. It's interesting that consumer advocacy groups don't seem to be too concerned about the validity issue, and to some degree neither do payers. A consumer advocate once told me, "Just give us all the data. We don't care if it's correct." Caveat emptor!

Graphic: WhyWeSuffer.com

Now here's something to be thankful for...

Personalize funny videos and birthday eCards at JibJab!

Vaccines! This week's New England Journal of Medicine has a study from the University of Pittsburgh that analyzed 125 years of weekly surveillance reports for infectious diseases, and today's New York Times has an article about the study. By analyzing time periods before and after introduction of vaccines, the investigators were able to estimate that in the last decade 99% of cases of childhood diseases have been prevented. Quick, someone please call Jenny McCarthy!

Turkey Links

We at the Ye Olde Humble Controversies Blog (YOHCB) wish you a safe and happy Thanksgiving. We have lots to be thankful for including the many tireless state and federal partners in infection prevention, fantastic infection preventionists, colleagues across many clinical disciplines and our readership. Thank you!

While you are out and about or gathered around a turkey or television, you might want to browse these studies/posts which we haven't covered yet. Just promise that you won't read any while driving, OK?

Links:

1) Stephan Harbarth's group has published in BMJ Open a surgical patient sub-study under MOSAR comparing the impact of (1) enhanced hand hygiene promotion (2) universal MRSA screening and decolonization  or (3) risk-factor based, targeted MRSA screening and enhanced hand hygiene in 10 hospitals encompassing 33 surgical wards. This quasi-experimental study found that neither intervention alone reduced monthly MRSA clinical culture rates. However, the combined intervention (3) was associated with a 12% reduction in monthly clinical cultures.

2) The CDDEP Blog has a new post by Stan Deresinksi covering Antibiotic Stewardship Programs and Education. Stanford's antimicrobial stewardship program has just posted an online course covering appropriate antimicrobial use.

3) Think Like an Anthropologist (HBR). Even though this is a business-oriented article, I think its points are generalizable to health-related administrative data. Key portion of the article: "efforts are typically driven by econometricians, computer scientists, and IT technicians—the people who are expert in database management. They understand digital information, but they don’t always understand how to get from information to meaning. So they boil the data down to percentages, treating random comments (and pictures of people with foil on their legs) as noise. But if you want meaning, you have to think like an anthropologist."

4) Marin Schweizer and colleagues from CDDEP recently published an study in ARIC looking at whether clinicians prescribed antibiotics based on national MRSA or local MRSA data. Clinicians appeared to prescribe linezolid and clindamycin based on national MRSA data but not local data suggesting that providing better local antibiogram data might help with outpatient antimicrobial stewardship efforts.

5) There's a really nice paper in Pediatrics that explores the importance of clustering of unvaccinated patients in the recent California pertussis epidemic. It appears that non-medical exemptions may be contributing significantly to the spread of pertussis. h/t Melissa W

6) There's a new study in PLoS Medicine that recalculated the mortality associated with pandemic 2009 H1N1. This study found mortality to be ten times prior low estimates but in line with a typical influenza season. NPR covered the study. h/t Jonathan Eisen

7) The physician at the center of a Las Vegas clinic Hepatitis C outbreak received a life sentence. h/t Daniel Sexton

8) Finally, we have nothing to worry about. The dragonfly's nano-tech black silicon will eliminate those nasty bacteria. It'll even kill spores.  h/t Judy Stone

Turkey: Best recipe (h/t MO Wright)

Photo Credit: Bob Evans

CRE decolonization: Can we? Should we?

There's a new paper in American Journal of Infection Control which poses an interesting question: can CRE (carbapenem-resistant Enterobacteriaceae) be eradicated from the gut? Given the increasing problems with these organisms, decolonization could play an important role in their control.

This study was performed at a large tertiary care hospital in Israel where active surveillance is performed on admission and weekly in targeted populations. Unfortunately the design of the study makes it difficult to interpret. There were 4 study arms: treatment with oral gentamicin, treatment with oral colistin, treatment with oral gentamicin + oral colistin, or no treatment. In part, the susceptibility of the colonizing strain dictated the study arm (e.g., patients with a colistin-resistant, gentamicin-susceptible strain were treated with gentamicin, unless they did not consent to treatment, in which case they were assigned to the control group). If the patient's isolate was susceptible to both drugs, they were randomized to either drug or to combination therapy. Treatment was given for 60 days or until eradication (defined as 3 consecutive negative rectal cultures with PCR performed on the 3rd negative sample), whichever came first. In the end, 26 patients received gentamicin alone, 16 colistin alone, 8 received both, and 102 were untreated. Eradication occurred in 42% for gentamicin, 50% for colistin and 37% for combined treatment. Only 7% of the untreated patients spontaneously decolonized.

What conclusions can we draw?

1. Spontaneous decolonization is a rare event.
2. It appears that some patients (one-half or less) can potentially be decolonized or at least suppressed while on treatment. Of note, 2 patients in the gentamicin arm, 4 in the colistin arm, and 2 in the combo arm relapsed. It would be interesting to know whether patients who had CRE eradicated remained culture negative for the long-term (e.g., 3 months or 6 months after treatment). 
3. Given that colistin remains one of the most important drugs for treatment of these infections, it worries me that widespread use of this drug for decolonization could result in resistance. Indeed, colistin resistance was reported in 1 of 16 treated patients, and 6 of 26 patients in the gentamicin arm developed gentamicin resistance.

In the end, how do we use the data from this study? I suppose if I practiced in a hospital with high rates of CRE colonization, I would be tempted to try decolonization for very high risk patients (e.g., neutropenic leukemic patients). I would favor use of gentamicin if the isolate were susceptible. But it would make me very nervous.

Photo: Klebsiella pneumoniae, CDC

One way of Getting to Zero

Favorite quote: "I can disagree with gravity but it doesn't mean that it no longer applies to me."

 

Wipe it down!

There's a short paper in American Journal of Infection Control that looks at stethoscope contamination. The authors cultured 112 stethoscopes; 48 (43%) were found to have pathogens on the diaphragms. Of the 50 pathogens isolated, 3 were gram-negative rods, 4 were E. faecalis, and 43 were S. aureus. Of the S. aureus isolates, 18 were MRSA. Despite the fact that stethoscope contamination is common, I see little effort in the infection prevention community to address this. So here's another reminder to wipe down that stethoscope!

Photo: KREM.com

Re-designing rooms and re-engineering care to reduce infections

There's an article in the Wall Street Journal on the hospital room of the future. It notes elements of architectural and product design that can reduce the transmission of infection. Take a look at the graphic above. You'll note, for example, that on entering the patient room the sink lights up in red to remind healthcare workers to wash their hands. There are a number of other examples of using design to reduce infection in the graphic. One not specifically designed for infection prevention that may still be useful in preventing infection is the large video monitor on the footwall of the room. Let's say I'm a consultant and I have influenza. I could still interact with the patient without being physically present, not feel guilty about staying home, and not risk transmitting influenza to the patient. Obviously I could not perform all the elements of a physical exam, but not all follow-up visits require an exam, though I have heard rumors that some doctors perform perfunctory exams for billing purposes only. Moreover, does every consultant and medical student need to exam the patient every day? Think of how many contaminated stethoscopes and dirty white coats are touching patients every day with the majority of those interactions adding no value to the care of the patient. Perhaps one physician could examine the patient and the rest skype in.

I've been thinking lately that we really need to carefully exam all the things we do in hospitals and then engineer out the opportunities for transmission of infection. I was reminded of this by a paper in Transactions on Healthcare Systems Engineering, which examines something as simple as how ICU nurses cover patients for each other while on breaks. This paper points out that by providing a structured coverage arrangement the number of unique persons interacting with any given patient are significantly reduced, which potentially reduces transmission of infection. I bet there are many such  examples where re-engineering patient care could reduce the potential for infection transmission.

Graphic:  Wall Street Journal