Central line + positive blood culture = CLABSI (not!)

There's a thoughtful commentary in a recent issue of Clinical Infectious Diseases by Tom Fraser and Steve Gordon at Cleveland Clinic on problems related to CDC's central line associated bloodstream infection (CLABSI) case definition. We've blogged about this before. The definition is old and was designed to maximize sensitivity long before anyone thought about public reporting. But the issues of poor specificity of this definition are haunting many of us, particularly those who work at hospitals with cancer centers. Unfortunately, neutropenic cancer patients not uncommonly have translocation of enteric flora across their intestinal mucosa and the resulting bloodstream infection in the presence of a central line forces us to label these as CLABSIs, even though these infections are not at all related to the central line. Ten years ago no one cared about this surveillance technicality. Now, in the era of public reporting this is a big problem. In fact, nearly every "CLABSI" in the medical ICU of my hospital falls into this category. Fraser and Gordon show us how this is handled at their hospital with a modification to the CDC definition that is used for internal purposes. Hopefully relief is on the way. CDC is very interested in this issue and has assembled a committee that is actively evaluating the issue.

Open Source ARIC Journal: Now Open!

As we mentioned back in June, there's a new open-source BMC journal titled - Antimicrobial Resistance and Infection Control (ARIC).  The website for submissions is NOW active. Per Andreas Voss, the Editor-in-Chief, manuscripts are being accepted and the "under construction" sign will be removed after the first paper is published. In addition to Andreas, Jan Kluytmans is the Deputy Editor and Didier Pittet is the Executive Editor, so this will be an excellent addition to our field and the benefits of having an open-source option can't be over emphasized. Submit your manuscripts here and read more about what types of papers they are looking for here.

Journal website: www.aricjournal.com/

No more sleepy doctors?

Photo: Sleepless and Tired

Yesterday's New York Times Magazine had an article on the new ACGME residency work hour rules written by a pediatric cardiologist. I think it presents a balanced view of the the topic and it interests me for several reasons. I recall several scary episodes from my own sleep-deprived residency days, including giving nurses verbal orders in my sleep, but I was luckier than one of my colleagues who demolished his car after a night on call. As a hospital epidemiologist, my interest in the new rules revolves around whether there will be any impact on medical errors, which the article points out is still open for debate. As a medical educator, I'm also interested in the impact on medical education, which the article does not address. Will the decreased hours and the associated decrease in clinical experience lead to less competent doctors? And the rules have also impacted the work environment in the hospital, a topic I addressed in an essay published last year. While I favor the rules and strongly support having well-rested doctors, I do worry about the adverse unintended consequences.

MRSA in Decline: England Edition

Don't know what I want
But I know how to get it
I wanna destroy passerby

-Sex Pistols "MRSA? in the UK"

MRSA rates have just reached their lowest levels in recorded history. Per a BBC report, there were 97 cases in the entire NHS in June, which represents the first time rates have been below 100. 25 hospitals had no MRSA cases in the month. C. difficile cases are also falling, so the decline is likely due to an overall emphasis on infection prevention including hand hygiene, which would impact both infections. Good news, overall.

BBC report
Guardian report

Architectural yogurt for our hospitals?

Professor Jessica Green is an engineer and ecologist from the University of Oregon and the founding director of the Biology and the Built Environment (BioBE) Center that bridges biology and architecture. In this recent TED video she describes a study where they compared the diversity and origin of bacteria in hospitals to the outdoors. Her conclusions are intriguing in an intermediate outcome sense.  Enjoy.

Contact precautions, and why I hate them, entry number next

Regular readers of this blog know that we’ve raised many questions about contact precautions (CP). We have very few arrows in our quiver to fight multiple-drug resistant organisms (MDROs). CP is one of them. So naturally it has become infection prevention dogma that CP is necessary to control MDRO spread. Never mind that the effectiveness of CP has really only been demonstrated in outbreak settings, that adherence to CP is often terrible, and that CP likely has several nasty unintended consequences that can harm patients. The bottom line? We desperately need more research, both to address the effectiveness of CP at preventing pathogen transmission, and to address the potential unintended consequences of widespread application of CP.

Regarding the latter (unintended consequences), we have two recent additions to the literature courtesy of Eli and his homeys back in Maryland. The first study, led by Dan Morgan, examines the relationship between CP and adherence to several quality-of-care process measures (e.g. SCIP, pneumonia, CHF, acute MI), and the second study, led by Hannah Day, examines the relationship between CP and depression among acute care inpatients.

I have an obvious conflict of interest and will therefore not critique either study. Instead I will leave it to you, dear reader, to assess their quality and to leave any comments, positive or negative, that you wish.

Things that make you go "hmmm"...

I’ve been in an undisclosed location for the past week or so. Hint—if I were to hop on the above watercraft and drive directly across the above body of water, I’d be in the city that in the Potawatomi language translates (roughly) as “fine land”.

In among my beach reading I ran across this article, about a recent biowarfare exercise:

“AVI BioPharma, Inc., and the Naval Research Center recently announced the successful completion of a rapid-response exercise conducted by the Joint Project Manager Transformational Medical Technologies…..In a total of 18 days, AVI conceived, designed and manufactured two novel RNA-based drug candidates, one against a Gram negative bacterial target and one against a viral target.”

Eighteen days to conceive, design and manufacture a drug active against a Gram negative pathogen! Meanwhile, the only option for treatment of many multiple-drug resistant Gram negative infections is a drug that’s over 50 years old.