An abundance of "abundances of caution"

Googling “abundance of caution Ebola” yields 213,000 hits and a treasure trove of misguided responses to Ebola fears. You can even refer to this excellent Washington Post article about how to make “an abundance of caution” work for you! It’s to the point now that if I hear “abundance of caution” being used in a sentence about Ebola, I translate it to “what I am suggesting makes no actual sense but demonstrates my extreme seriousness about fighting the very idea of Ebola”. 

Some “abundance of caution” (AOC) actions are completely off-the-rails, like preventing students or teachers from attending schools when they had no risk for Ebola exposure, while others may appear reasonable but have no scientific basis (like the excessive movement restrictions some states have applied to asymptomatic returnees from outbreak areas). Another example of the latter category of AOC actions recently took effect in California, as CalOSHA issued updated Ebola guidance for hospitals. The CalOSHA guidance for personal protective equipment meets CDC recommendations, but allows only one option for respiratory protection (PAPR) and only one option for skin covering (full body coverall). I’ll outsource the rest of this post to a SHEA press release from last week. Suffice it to say that I sincerely hope they dial this back, and that it doesn't become a standard for federal OSHA guidance.

SHEA Supports Scientifically Sound Approaches to Ensure Protection for Healthcare Personnel Fighting Ebola

November 24, 2014 (Arlington, VA) – The Society for Healthcare Epidemiology of America (SHEA) is dedicated to the prevention of infection in healthcare settings, including the protection of healthcare personnel (HCP) who provide care to patients with known or suspected Ebola virus disease (EVD). 

SHEA supports the current Centers for Disease Control and Prevention (CDC) guidance on Personal Protective Equipment (PPE) to be used by HCP caring for patients with EVD. This guidance is consistent with the established science regarding how EVD is transmitted.

Recently updated guidance from California's Division of Occupational Safety and Health (Cal/OSHA) meets the CDC recommendations, but specifies only one form of respiratory protection (powered air purifying respirator (PAPR)) and only one form of barrier protection (impermeable coverall) for all inpatient and emergency department (ED) care of those with suspected or confirmed EVD. However, there are no data to suggest that these specific forms of PPE provide better protection for HCP than alternatives that are also included in CDC guidance (e.g., N95 respirators, fluid impermeable hoods, AAMI-4 gowns and leg coverings). 

There are several types of PPE that provide full protection against Ebola transmission, and the local preference of nurses, physicians and other HCP is paramount to select the best PPE for their facility (from among CDC-adherent options). Considerations of familiarity, tolerability (e.g. discomfort, overheating), risk for self-contamination during doffing, and amenability to training all require local input. Thus wide adoption of the narrow requirements established by Cal-OSHA could have unintended adverse consequences. For example, hospitals that have already trained their HCP in safe use of AAMI-4 gowns may inadvertently increase exposure risk by switching to unfamiliar coveralls that are widely considered to be more difficult to doff without self-contamination. Furthermore, mandating PPE that is excessive for the fluid risk of a suspected or confirmed EVD patient results in unnecessary impediments to timely and effective clinical care (e.g., requiring PAPR and coverall for evaluation of an ED patient with low grade fever and no other symptoms). Since most suspected EVD patients cared for in US hospitals test negative for EVD but may have other life threatening conditions that require timely therapy (e.g., malaria), such impediments can lead to harm. Finally, unnecessarily narrow limitations on PPE types will exacerbate already critical PPE shortages and limit the ability of US hospitals to be prepared to care for those with known or suspected EVD. 

HCP have a right to a safe work environment during the care of patients with any communicable disease, including Ebola. SHEA believes that the current CDC guidance, when practiced correctly and reinforced by adequate training of HCP, protects HCP from Ebola transmission. 

Photo by John Spink

Maybe Sheldon was right...

A new study from Ohio State University published in the American Journal of Infection Control sought to determine whether buses are contaminated with MRSA. Forty buses in a midwestern city were sampled. MRSA was detected in over 60% of the buses, with seats (33%) and seat rails (30%) the most common sites of contamination.

Those of you who are fans of the Big Bang Theory know that Sheldon Cooper, PhD, ScD, a genius theoretical physicist who has never learned to drive, wears bus pants when using public transportation. In the video clip below, Sheldon explains the concept.

Maybe we should have public reporting of contaminated buses. Because no American should have to wear bus pants, ever. Bazinga!

something something antibiotics something something

It's been a crazy couple weeks out here on the edge of the prairie. Clinical service, grants, papers, holidays, Ebola?, the ESCMID-SHEA course in Phuket and SHEA2015 have swallowed up my fall. Get those SHEA abstracts ready folks - the deadline is fast approaching - January 16th.

In the middle of this chaos, the CDC's Get Smart About Antibiotics Week seemingly appeared out of nowhere and CDDEP investigators just published a very nice antibiotic use point prevalence study in 6 US hospitals in this month's Lancet ID to coincide with the 'Get Smart' Campaign. Nikolay Braykov and Dan Morgan led the study and Nikolay wrote up a nice post describing what they found, which I've excerpted below:

We undertook a chart review study at six institutions – two teaching centers, three community hospitals and one VA – looking at the indications for starting antimicrobials, the use of culture and radiology results and the patterns of modifying empiric therapy in the first five days of treatment. We found nearly two-thirds of inpatients were receiving antibiotics, with empiric starts dominated by combinations of vancomycin, piperacillin/tazobactam and fluoroquinolones. It is likely that a lot of those initial prescriptions were unnecessary, as 30% of patients lacked fever or abnormal white blood cell counts at the start.

Appropriate cultures (on or before start of therapy) were collected from 59% of patients, and although 60% came back negative, only 22% of all evaluated patients and had their antibiotics narrowed or stopped (Figure). More specifically, 22/59 (37%) of patients with negative urine culture and 11/22 (50%) of those with negative blood culture had antimicrobials stopped or narrowed. Of pneumonia patients with negative chest imaging that proportion was 12/50 (24%).

Narrowing or discontinuation (of antibiotic therapy) was more likely when cultures were collected at the start of therapy and no infection was noted on an initial radiological study. In turn, escalation was associated with multiple infection sites and a positive culture (see table below).

It seems like diagnostic uncertainty drives a lot of possibly unnecessary antibiotic use. These results underscore not only the need for rapid diagnostics, but also the importance of mechanisms to assure tests are ordered in time and their results are actually used to optimize therapy – goals attainable through better stewardship programs and physician education.

A great point made recently is that the government’s resistance action plans should include steps to incentivize and expand the training of more ID physicians. Although the threat of drug resistance gets more public attention each year, “getting smart” about antibiotics, including their timely withdrawal and adjustment, ultimately requires the buy-in of current and future prescribers. 

Band Aid 30 (West Africa 2014)

Band Aid, a charity group founded by Bob Geldof and Midge Ure in 1984, raised money to combat starvation in Ethiopia. The original song (despite controversial lyrics) led to the successful Live Aid concerts the following summer. With the current plight of Ebola in West Africa, they formed a new group to sing revised lyrics like "where a kiss of love can kill you and there's death in every tear" to help raise money to combat the epidemic. I would have written where a break in PPE protocol can kill you and, of course, epidemiologically speaking, there's not death in every tear. The song is available on iTunes and a CD will be released soon. And if you dislike the song or want to give more, you can head over to Oxfam, MSF,  MSF (USA), UNICEF, or the CDC Foundation.

Wanted: Ebola test with perfect negative predictive value at time zero

The tragic death of Dr. Martin Salia has triggered a spate of news articles about the limitations of Ebola diagnostic testing. According to news reports, Dr. Salia tested negative twice early in his symptomatic period, and was already quite ill by the time he tested positive.

The fact that the most sensitive Ebola virus diagnostic test (PCR applied to a blood sample) may not be positive until 3 days after symptom onset is well known, however. The reason for this has to do with the pathogenesis of Ebola virus infection. The point of entry and initial replication for Ebola is the “dendritic” cell. Present in large numbers in the skin, mucosa and intestinal lining, dendritic cells are sentinels, guarding the interface between the human immune system and a hostile environment. They encounter invaders, engulf them, and present their antigens to cells of the adaptive immune system. Dendritic cells carry the virus to lymph nodes and other organs of the “reticuloendothelial system” (liver, spleen). So before the virus reaches detectable levels in the blood, there may be hours-to-days of replication in these cells and organs, along with symptoms of fever and fatigue. A test, even a very sensitive test, that is applied to blood will not detect the virus until it appears in the bloodstream in larger numbers. 

This lack of a rapid and accurate diagnostic test early in the Ebola disease course is a major problem—not only for early initiation of therapy for those infected, but also for the management of “persons under investigation” (who may require Ebola-level isolation precautions for several days while awaiting a negative test that has been taken at least 3 days after symptom onset). 

But this problem plagues infectious diseases diagnostics generally. As this recent Lancet ID article points out, the lack of early and sensitive diagnostic testing is one reason why so many patients in our hospitals receive days of unnecessary antimicrobials. More on this study later, perhaps from Eli, one of the authors!

Image by Sean Gallup, Getty Images

Why can't we easily clean our stethoscopes?

I just finished two weeks on the inpatient internal medicine service. When we round on the service every morning, I insist on 100% hand hygiene and 100% stethoscope hygiene but one of these targets is far easier to achieve than the other. As Mike mentioned last year, almost 50% of stethoscopes are contaminated with pathogens including S. aureus and MRSA. Despite this level of contamination, hospitals have done almost nothing to make cleaning them quick and easy. Like many (? all) hospitals, we have hand rub dispensers every few feet but nothing easily available to clean our stethoscopes. I usually end up "bothering" nurses to give us a few alcohol prep pads, but this uses up their daily supply and generally seems like an unnecessary barrier. Why can't we have wipes next to the hand rub dispensers outside of every room? That way we can actually achieve 100% stethoscope hygiene. If we don't develop good systems, we can't expect good results. How do you guys practice stethoscope hygiene at your hospital?

Getting to zero

By my count, there are now zero persons in the United States who are actively infected with Ebola virus.  This is the perfect time to donate your time or your money to Ebola response in West Africa.

Also, Kaci Hickox still doesn't have Ebola. She should be allowed to go bowling.

Finally, one observation about our weirdly, uniquely American response to Ebola virus. The CDC Guidance for Monitoring and Movement Restriction treats healthcare workers who have "direct contact while using appropriate personal protective equipment (PPE) with a person with Ebola" differently based upon whether they were caring for patients in countries with or without "widespread Ebola transmission". Thus brave volunteers returning from West Africa are under more stringent monitoring and movement restriction guidance than are those who might care for a patient in New York, Texas or Iowa. Yet if you compare the ratio of 'healthcare worker acquisitions/Ebola infected patients' in the US versus West Africa, I'm not sure there is any contest (2 acquisitions/9 Ebola patients = .22--what's 22% of 13,268, the total number of cases thus far in West Africa?).  This isn't an argument to be more restrictive about those who care for Ebola patients in the US, it's an argument to chill the #&*% out about humanitarian healthcare workers returning from the outbreak zone.