MRSA search & destroy: It's time to surrender

Over the past five years, we've blogged many times about active detection and isolation for MRSA (ADI, aka "search and destroy"), focusing on our doubts about its effectiveness and the stupidity of legislative mandates for this practice. Nonetheless, there remain some diehard believers. A new perspective piece in The Lancet takes another stab at analyzing the available evidence in order to guide practice. The authors focus on the large studies with the strongest designs. In a nutshell, they conclude that these studies demonstrate that ADI is either not effective or only effective as part of a bundle of interventions (i.e., combined with hand hygiene and/or MRSA decolonization). And in the case of bundles, is ADI an effective component? One study that specifically addressed this question found that ADI did not further reduce MRSA rates when added to optimizing hand hygiene compliance and chlorhexidine bathing. To provide further context the authors point out a number changes that have occurred since ADI was first touted as the best thing since sliced bread:  MRSA rates have decreased, new drugs to treat MRSA have been released, and other multidrug-resistant organisms have emerged. And then the unintended adverse consequences (fewer doctor and nurse visits, safety issues, patient dissatisfaction, anger and depression) need to be considered. The authors wisely point out that "isolation is the prototypical punishment in all societies."

This perspective piece is well reasoned and nicely summarizes a very complex topic in three pages. It should be required reading for everyone on both sides of this debate.

Photo: Paul Martinka, New York Post

Evidence, schmevidence! Occupational medicine edition

The LA Times reports today that another porn star has become infected with HIV. This brings the total of infections to three in the past year. Although porn workers are required to be HIV tested every 14 days, condoms are not mandated. The lack of mandate is unfortunate given that we have great evidence for the effectiveness of condoms in reducing HIV transmission.

Now let’s switch gears and talk about healthcare workers. Increasingly, hospitals are mandating influenza vaccination. A new paper in the latest issue of the American Journal of Preventive Medicine by investigators at Johns Hopkins describes a systematic review of the literature on mandatory influenza vaccination for healthcare workers. One key finding was that mandating influenza vaccination increased compliance (imagine that!). But (and it’s a very big but) there was either no demonstrated statistically significant reduction in sick leave after mandating vaccination or no evaluation was performed in the studies reviewed. Moreover, none of the studies evaluated the impact on patients. At the end of the day, we still have no evidence that vaccinating healthcare workers reduces influenza in hospitalized patients. That doesn’t mean vaccination is not a good idea. I would argue that bare below the elbows is a good idea, but I’m quick to acknowledge that we don’t have data that it reduces infections, and therefore I don't support a mandate.

So here we have two industries struggling with evidence: one won’t mandate a proven prophylactic strategy, and the other seems quite comfortable mandating a prophylactic strategy that isn't proven. The root cause in both cases appears to be the same—an attempt to please the customer. It’s a whole lot easier for hospitals to mandate flu vaccine and publicly pat themselves on the back and tout how they are serious about patient safety than to develop and enforce policies and practices that keep healthcare workers home when they are sick.

Photo: Francine Orr, Los Angeles Times

Give Directly-Observed Hand Hygiene Compliance Monitoring a Chance

As I've said before, "It's amazing how little evidence is required before infection prevention interventions are adopted." This phenomenon is particularly evident in the setting of automated hand hygiene monitoring systems. Few trials have been completed that have assessed the efficacy, effectiveness or cost-effectiveness of these systems, at least as of our recent systematic review.  However, it appears that many facilities are purchasing these systems anyway. Why is this?

It appears that there are two potential limitations of directly-observed hand hygiene monitoring driving the purchase of automated systems: (1) the fear that the Hawthorne effect renders all direct observations invalid and (2) the idea that all hand hygiene opportunities must be counted, i.e. it's unacceptable to sample opportunities. There is a third potential reason for adopting these systems - anecdotal reports that automated systems improve compliance. However, there is little published evidence that compliance increases are sustained and some evidence that automated systems actually decrease compliance.

With the potential limitations of directly observed compliance monitoring in mind, our research group just completed a study published in ICHE that sought to determine if/when the Hawthorne effect appears in hand hygiene observation data. The idea being, if it takes some period of time for HCW to know they are being observed, shorter periods of hand hygiene monitoring could be less susceptible to bias from the Hawthorne effect. After 3,432 hours of observations and 11,444 witnessed opportunities in a multi-center study, we calculated that room-entry compliance increases after 38 minutes and room exit compliance increases after 14 minutes and then again after 50 minutes (Figure below). Thus, it appears that limiting direct observation periods to less than 15 minutes limits the impact of the Hawthorne effect.

The other aim of our study was to determine the number of hand hygiene opportunities that must be observed to have an adequate sample size for comparison. For example, if hand hygiene compliance in your ICU is 80% this month and you would like to get it to 90% next month, you would need to observe 108 opportunities in each month to have enough power to detect a difference. We provide a table (below) so that anyone can quickly determine the number of observations in a month/quarter/year needed to compare time-periods or units/wards or facilities. We hope you find this information useful and that you'll still give directly observed hand hygiene compliance monitoring a chance.

Nightmare in Liberia

I posted yesterday on the nightmare unfolding in Liberia, as the health care system has collapsed under the weight of the Ebola outbreak, with civil order breaking down as entire sections of Monrovia are placed under quarantine. Last night I spoke with a friend of ours, Chesca Colloredo-Mansfeld, the Executive Director of miraclefeet, an organization dedicated to treatment of clubfoot in developing countries, including Liberia. As you might imagine, the Liberia clubfoot treatment clinics have had to focus all of their efforts on Ebola response. The situation there is truly awful—below is an excerpt from an email exchange that Chesca forwarded: 

"…help is really needed. He [Augustine Chiewolo, head of the Liberia clubfoot treatment program] told me that his cousin’s body was just removed from her house yesterday. It took four days for her to be removed. Her two remaining children are isolated in a church—and he is trying to make sure that people will deliver them food. He said that if they do get sick, there is no one who is willing to transport sick people to the hospitals, so many people aren’t able to access treatment. People are dying of ordinary illnesses because they are isolated as soon as they are ill and don’t access treatment."

Augustine is currently in the U.S., working with miraclefeet to gather supplies to send back to Liberia. A list of supply needs below was provided by the Liberian Ministry of Health:

If you are interested in helping, you can do so either by donating to miraclefeet (online here or by mail to miraclefeet, 410 West Main Street, Carrboro, NC 27510—please note that it is for Liberia in the dedication line and it will go towards buying critical supplies), or if you prefer to send donated supplies directly you can send to: Augustine B. Chiewolo, 1000 Andrews Ave, Collingdale PA 19023-4004—any donated materials need to arrive to that address by September 10th.

Augustine Chiewolo

To CDC or not CDC - That is the Ebola Question

It's been a busy couple weeks out here in infection control land. We had our SHEA 2015 planning committee meeting in DC. There's an exciting program planned - can't wait to share it with you. While I've been planning Ebola symposia for the May meeting in Orlando, Dan and Mike have been very busy discussing and implementing Ebola management plans. If you haven't had a chance to read their excellent posts, you can peruse them all here.

The debate over the CDC droplet+contact precautions guidance is strangely similar (in an opposite day kinda way) to discussions around N95 masks during the 2009 H1N1 outbreak. To remind yourself of the debate, you can read one of Dan's 2009 posts on the topic. What is almost ironic is a quote included in the post: "when did influenza become Ebola." What is actually ironic is that back in 2009/2010, CDC recommended "respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza." Yet now, CDC does not recommend N95s in most clinical situations for Ebola. And if you're keeping score, in 2009 CDC wanted "higher-level" protection and hospital epidemiologists wanted "lower-level", while in 2014 most hospital epidemiologists are implementing policies that extend way beyond CDCs recommendations.

All of that is by way of background to a thoughtful commentary in Annals of Internal Medicine by Michael Klompas, Daniel Diekema, Neil Fishman and Deborah Yokoe. The authors carefully review the data behind the CDC's current guidance and suggest that hospitals stick closely to the current recommendations. They claim that exceeding the CDC guidance could paradoxically increase health care worker risk and anxiety while also increasing cost and waste. They also suggest that exceeding "CDC's recommendations fans a culture of mistrust and cynicism about our nation's public health agency." The only thing I would add is that no matter what's included in your local Ebola management plans, don't forget the ice cream.

image source: The Onion

The horror

Mike recently posted about Emory’s state-of-the-art isolation unit, where the only two Ebola-infected patients in the U.S. have been treated. Compare that unit with this Ebola isolation unit set up in an abandoned school in Monrovia, Liberia.

 Or with this new Ebola treatment center being set up by Doctors Without Borders, in Monrovia, soon to be the largest Ebola treatment and isolation center in history. Large open tent, mattresses on the ground just feet from each other, no modern plumbing (see wash station in the corner)—it is easy to see how personal protective equipment might also need to be adjusted for those who spend hours on end caring for sick and dying patients in this environment. 

The recent news from Liberia is horrendous. Earlier this week the residents of West Point, described by one journalist as “the worst slum in Liberia, which makes it one of the worst slums in Africa, which makes it one of the worst slums in the world”, looted a school-turned-Ebola-isolation unit, freeing the isolated sick patients and making off with blood soaked sheets and mattresses. The entire community is now under quarantine, and is responding violently.

I spent several weeks in Liberia about 30 years ago, and I’ll never forget the conditions I saw at West Point. From the Washington Post:

"According to the United Nations Office for the Coordination of Humanitarian Affairs, which reported on the slum in 2009, there were only four public toilets servicing 70,000 residents. Using the toilet cost 3 cents, and bathroom operators estimated they got about 500 patrons per day. “The facilities can be smelled 50 meters away, with the floor of each squalid cubicle 15 cm deep in soiled newspaper that residents use to wipe their posteriors,” the service reported. “Staff use gloved hands to scoop the used paper into a wheelbarrow, which they lug to the nearby river or beach to dump its contents into the water.” Other residents prefer not to deal with all that, and instead use the beaches as public bathrooms. “Before I can take my first step into the sand [I see] the small black and brown piles underfoot,” a Providence Journal missive says. “A few yards ahead, a scattering of about a half a dozen or so small children squat, eyes towards the sea.”"

Most Ebola outbreaks to date have been smaller events, confined to rural areas. This is much different, and now that the epidemic involves a huge population center with no health care or public health infrastructure, it is hard to see how it will come under control anytime soon.


First two photos, by John Moore/Getty Images, third photo of West Point taken by me in 1983.

Emory's Ebola Unit

This NPR interview gives additional information about the unit.