Misguided mandates

Photo: New York Times

The Bangor Daily News is reporting that a bill being considered by the Maine legislature would mandate MRSA screening of high risk patients admitted to hospitals. I won't rehash all the writing we have done on active surveillance for MRSA, but you can see those posts here. So MRSA exceptionalism lives on, and more money will pour into the coffers of companies that produce MRSA test kits.

Another use for the checklist

A press report from the Society of Critical Care Medicine Meeting outlines a study with a simple, novel intervention to improve hand hygiene compliance. In this study, investigators in a surgical/trauma ICU added a question to their daily care checklist: Has anyone seen anyone else touch the patient without washing their hands in the past 24 hours? If the answer is yes, the name of the offender is recorded. The result of this simple intervention was improved hand hygiene compliance from 69% to 89%. Though there isn't much detail about the study given in the report, one could envision how this would integrate front-line providers into a continuous vigilance that could be quite powerful. One downside is that this would likely not work well outside the critical care setting.

Wash 'em

Here's a new hand hygiene video, which comes from Thomas Jefferson University Hospital.



Sure beats $1,000 fines!

Click here to read more about the hospital's hand hygiene efforts.

Another Friday, another feces post...

Recurrent Clostridium difficile disease is a huge problem—a nightmare for patients, and a recalcitrant challenge for clinicians and infection preventionists. So this week’s New England Journal of Medicine brings good news about fidaxomicin*, a new nonabsorbable macrocyclic antibiotic active against C. difficile. In a head-to-head trial with vancomycin, cure rates were equivalent but recurrence rates were significantly lower for fidaxomicin (15% versus 25% for vancomycin, in the modified intent-to-treat groups). Unfortunately, this difference held only for non-NAP1 strains. For the nasty, hypervirulent NAP1/BI strain, recurrence rates were 24% in both groups—meaning that for the majority (64%) of patients with other strain types, the difference in recurrence rates between fidaxomicin and vancomycin was even greater (7.8% vs. 25.5%).

Why? Fidaxomicin is more active against C. difficile (bactericidal rather than bacteriostatic), has a longer post-antibiotic effect, and is slightly narrower in spectrum than vancomycin. So it probably kills C. difficile better, for longer, and without as much disruption of the rest of the colonic flora. Further studies will be needed to investigate this further, and to determine why this effect is not seen with the NAP1/BI strain.

The accompanying editorial by Dr. Herbert DuPont is well worth reading, and raises questions about whether our initial therapy for C. difficile is too short in duration (in this study, 10 day treatment courses were used), and whether we’ll eventually be using a combination of antibiotics and immunotherapy to effectively treat and prevent C. difficile recurrences. That is, if stool transplants haven’t become the treatment of choice by then.


*This drug is made by Optimer Pharmaceuticals, and all of the authors have listed disclosures at the end of the article—three of the authors are Optimer employees

Extreme infection prevention

The new "didn't wash hands!"

There are differences of opinion on how to motivate healthcare workers to comply with infection prevention measures. Some hospitals favor carrots. Others prefer sticks. And then there's the University of Pittsburgh Medical Center's Rambo approach. As reported in the Pittsburgh Post-Gazette, the hospital has implemented a new policy to improve handwashing compliance. Attending physicians who fail to wash their hands are fined $1000, residents and fellows $250, and all others will be sent home. It makes the old Far Side cartoon with an alarm and sign (didn't wash hands!) seem quaint.

This approach worries me. It's punitive and adversarial, and in the end, may damage the trusting relationship between hospital epidemiology and healthcare workers that I think is needed for effective infection control. Other hospitals have had successes in improving hand hygiene compliance without resorting to such extreme measures. It's really quite rare for a healthcare worker to refuse to wash when confonted, and offenders can still be held accountable. It makes me wonder how bad hand hygiene compliance must have been to drive this approach.

Well, I sure hope this strategy works, since I shudder to think what could be next. Public stocks? Caning? Finger amputations?

Oh, one last question:  who gets the money?

Sterile gloves for drawing blood cultures?

Photo: RightHealth.com

A new study in the Annals of Internal Medicine evaluated whether blood culture contamination could be reduced if the phlebotomist wore sterile gloves. The study was performed in a 1600-bed Korean teaching hospital where all blood cultures are drawn by interns. The design was a cluster randomized crossover trial. Over 10,500 blood cultures were evaluated, and a contaminant was defined when only 1 of 2 of more blood culture sets were positive for skin flora (which in this study included enterococci).

The authors found a reduction in contaminated cultures from 1.1% to 0.6% (OR 0.57, p 0.009) with sterile gloves.

It's worth pointing out that cultures drawn through lines were excluded, as were cultures obtained in the Emergency Department (an area of high contamination rates in some hospitals), pediatrics wards and surgical wards. In addition, povidone-iodine was used as the skin disinfectant.

When I was a resident, all blood cultures were drawn by housestaff and I proudly recall that I never had a contaminated blood culture (and I did wear sterile gloves). But we had a vested interest in avoiding contaminants, as it would mean drawing more cultures and potentially extending the patient's hospital stay, all of which meant more work for us.

Guideline fail?

What if adherence to a guideline was associated with worse outcomes? How much independent validation of guideline recommendations should occur? Is it realistic to expect guidelines to be subjected to “real-world” testing prior to adoption?

If these questions intrigue you, you’ll be interested in a Pfizer-pfunded four-center performance improvement initiative that included education around the ATS-IDSA pneumonia guidelines and a prospective assessment of outcomes. As the authors report in Lancet Infectious Diseases this week, patients who received “guideline compliant” empiric therapy were more likely to be dead at 28 days than were those who received “guideline non-compliant” therapy.

Before you submit your resignations to IDSA and ATS, you should know that there were plenty of problems with this observational study—most of them are well-summarized in an accompanying editorial. The failure of the authors to consider appropriate de-escalation of therapy in their determination of guideline compliance is an especially big problem, given that antibiotic overuse has been linked to increased mortality in the ICU.

Despite the limitations, I think this study raises important questions about guideline-driven approaches to complex infections. It is interesting, for example, that guideline non-compliant empiric therapy was equally or even more likely to cover the eventually-isolated pathogen than was compliant therapy (85% vs. 81% of the time, respectively).