ID Match 2017: Turning point or artifact of "all in" approach?

The dust is still settling from this year’s ID Match, but at first glance it looks like a much-needed step in the right direction. Compared with last year, the number of unfilled positions (on match day, that is, which doesn’t count positions that will be filled after the match) is down to 80 from 117, and the number of unfilled programs is down to 54 from 82. This is not to minimize the pain for programs that didn’t match—>50 is still way too many, and comparable to the number of unfilled programs in 2014.

This dramatic shift from the trend of the last three years must be due in part to the “all-in” strategy that IDSA is pursuing (requiring that all ACGME positions be offered in the match, trying to minimize those positions offered before or after). The question is how much of this shift reflects an absolute increase in the number of trainees after the post-match numbers are included. For example, there is still the chance that interested individuals opt out of the match, hoping to snag a good position afterwards (obviating the expense, time and anxiety the interview circuit). 

The challenges to attracting the next generation of ID physicians remain daunting, and this one-year change in match results (temporally associated with a new “all in” policy) shouldn’t detract from the urgency of these efforts. We’ll have a much better sense of how we are doing (at least from the training program side) after another 1-2 years of the “all in” match. If programs and applicants continue to adhere to the "all in" approach (i.e. how will it be enforced?), at least it should give us a more accurate assessment of the supply-demand situation.

I’d welcome input from other program directors, IDSA leadership, and anyone else with thoughts on this year’s match results!

Mycobacterium chimaera outbreak: A practical review

Mike recently posted a “how to guide” for centers struggling with the response to this global outbreak. Now there’s also a review available online from ICHE—Mike and I each contributed, but the heavy lifting was done by our colleagues in Switzerland (Sommerstein, Schreiber, Hasse, Marschall and Sax). Table 1 in this paper (see below) provides practical interim suggestions. Check it out—and thanks to Cambridge for making this an open access article.

On a personal note: it’s been over a month since I posted on this blog—since the Cubs won the World Series, in fact. That event, and the US presidential election shortly thereafter, has me wondering if the world has somehow shifted on its axis. This is not a political blog, but it’s disingenuous not to recognize the anxiety we feel about an incoming U.S. administration that has had such a creative relationship with facts, with science, and with the idea of the common good. I’ll admit it has been hard for me to sleep some nights, amidst justifiable concerns about what may happen to our healthcare system, and to AHRQ, CDC, NIH, VHA, etc.

At some point, though, we just need to redouble our own efforts, wherever we are, to do the work we do best, and to speak up when things happen that threaten progress toward safe, effective and accessible health care. One of my favorite songs by Paul Simon has it right: “still, tomorrow is gonna be another working day (and I'm trying to get some rest).”

The almighty influenza vaccine

A recent study in Clinical Infectious Disease that analyzed the effectiveness of the influenza vaccine for the 2014-15 season was sent to me by a colleague. Wow. Overall effectiveness (for influenza A and B combined) was a whopping 19%, but for influenza A was 6%. Honestly, placebo is more effective than that. For the 2015-16 season, overall effectiveness was 47%, and 55% for influenza A.

CDC used to cite that the flu vaccine was 70-90% effective, but more recently they have revised that significantly. I was quite surprised when I looked at the CDC website today and I made the graph below from their data.

In 12 consecutive flu seasons, effectiveness hit 60% just once. If you average those 12 seasons, the effectiveness was 41%. We are sorely in need of a better vaccine. The CDC analysis begs many questions: Should hospitals make this weakly effective vaccine a condition of employment? Should SHEA take another look at its guideline? Does anyone still believe that we should fire healthcare workers that are not vaccinated with a vaccine that provides such poor protection? How many hospitals fire employees who come to work sick with influenza? Would you rather be hospitalized at a hospital with a mandatory flu vaccine policy or a hospital that makes a serious attempt to minimize presenteeism?

CAUTI SCHMAUTI ! (part 4)

A new paper in Infection Control and Hospital Epidemiology takes us another step closer to reclassifying CAUTI from a healthcare associated infection to a healthcare associated myth. Tom Fraser and colleagues at the Cleveland Clinic worked with their ICUs to reach consensus to limit urine cultures in patients with fever to kidney transplant recipients, neutropenic patients, patients with recent GU surgery, and patients with evidence of urinary tract obstruction. One year later, here’s what they found:

• There was no significant change in urinary catheter utilization (approximately 70% of patient days were associated with catheter use 1 year before and after implementation of changes in ordering urine cultures).
• The number of urine cultures ordered fell by ~50%.
• The CAUTI rate fell from 3.0 to 1.9/1,000 catheter days, a significant reduction of 33%.
• There was no change in the rate of healthcare associated bloodstream infections, and no change in the subset due to Enterobacteriacae, which implies that there was no increase in bacteremic urinary tract infections. The potential for bacteremia is a major reason for treating CAUTI.

A similar study from Mayo Clinic showed similar findings (50% reduction in urine cultures ordered and a 30% reduction in CAUTI).

It would be interesting to know how many cases of C. difficile have been caused by treating this noninfection, or as the Cleveland authors call it, “an artificial construct designed to reflect clinical events for surveillance purposes.” And as we become more serious about antibiotic stewardship, “CAUTI” should be viewed as low hanging fruit.

In previous posts on this blog (here and here) there have been discussions questioning the existence of CAUTI. We now seem to be reaching a tipping point where it’s becoming increasingly clear that the opportunity cost of this medicalized artificial construct outweighs the benefit of continued focus.

Annual US Deaths from MDRO: 23,000 - Deaths from Alcohol Hand Rub Fires: Zero

I just returned from the Healthcare Epidemiology Training course in Ho Chi Minh City, Vietnam where I had a wonderful time interacting with the students and other faculty. Thanks to Professor Le Thi Anh Thu, we had the opportunity to tour an 1800-bed hospital in the city and observed many barriers to infection control including an average daily census greatly exceeding the bed capacity; many patients are forced to share beds with other patients. However, in one area Vietnam is far superior to the United States - they allow alcohol hand rub at the bedside! You can see Joost Hopman, Andreas Voss and I touring a medical ICU in Vietnam - notice the green hand rub dispensers at the end of the beds.

In the US, fire code prevents alcohol hand rub from being placed at the bedside rendering the practice of the WHO 5 moments impossible. Healthcare workers simply don't have the time to leave the room to practice hand hygiene after each contact with the environment or patient. 

Here is the WHO's take on the fire risk of alcohol hand rubs: The benefits of the alcohol in terms of infection prevention far outweigh the fire risks . A study in Infection Control and Hospital Epidemiology (Kramer et al 2007) found that hand rubs have been used in many hospitals for decades, representing an estimated total of 25,038 hospital years of use. The median consumption was between 31 L/month (smallest hospitals) and 450 L/month (largest hospitals), resulting in an overall consumption of 35 million L for all hospitals. A total of 7 non-severe fire incidents were reported. No reports of fire caused by static electricity or other factors were received, nor were any related to storage areas.

So let's review the US situation:

Deaths from resistant bacteria? 23,000

Deaths from alcohol hand rub fires? 0

Changing state fire codes to allow alcohol hand rubs at the patient bedside? Priceless

108 years

This one is for Steve Goodman:

A few more videos of this iconic Cubs fan who died too young:

The M. chimaera How-to Guide

A few cases at a time, the M. chimaera outbreak associated with heater cooler units continues to grow. For reasons unclear to me, the response from CDC and FDA to this train wreck in slow motion has been underwhelming. We continue to field calls from hospitals struggling to deal with an approach to the outbreak. On today’s IDSA list-serv (IDea Exchange) Dr. Luther Rhodes wrote: “The silence is deafening. I call on those physicians with hands on experience in evaluating post open heart patients referred to ID for evaluation of concerns, signs or symptoms of possible NTM infection to speak up loudly and clearly. Lessons learned, protocols developed, evaluation and testing tools learned dealing with large scale regional patient notification should in my opinion be shared…”

We have posted several times on this topic, but I thought it might be useful to summarize how a hospital could approach this problem in a single post. To view older posts, type chimaera in the search box in the top right hand corner of your display.

Step 1: Determination of risk
Whether you have seen a case or not, the first question is whether your hospital has used the LivaNova Sorin T3 heater cooler unit (HCU) in the last six years. If the answer is no, there is no immediate action you need to take. If yes, then the investigation begins, as you must assume the units are contaminated, regardless of the manufacturing date.

Step 2: Risk mitigation
If you are currently using the LivaNova (Sorin) T3 unit, the most important risk mitigation strategy is to get the units out of the operating room. The molecular epidemiology clearly points to contamination of the HCUs at the manufacturing facility, which allows the units to produce an infectious bioaerosol that contaminates the operative field. Separation of this bioaerosol from the operative field is the key to eliminating the risk. Why the FDA won’t clearly state this is very puzzling.

At the University of Iowa Hospitals and Clinics our engineers were able to quickly (within a few days) devise a solution by creating a 6” x 6” hole (see photos) through the operating room wall on the semi-restricted side of the room. The area identified for creation of this portal was determined by hose access to the OR table with minimal interference with staff and equipment; access to power; and the ability to leave proper corridor width per life safety code. Testing demonstrated that positive pressure was able to be maintained in the OR after creation of the portal. The portal itself with a sliding door was constructed of Corian in some cases and stainless steel in others. A hose protection mat was placed in the ORs to protect the HCU hoses and to provide a ramp effect for equipment to be relocated as needed during the cases. One advantage of the T3 HCU is that remotes can be purchased that allow the perfusionist in the OR to control the HCU located outside of the room. Once the HCUs were moved out of the OR, we demonstrated no difficulty with appropriate heating or cooling. Remember, given the long incubation and detection period of these infections (maximum 6 years to date), if you do not eliminate the risk now, you will likely be chasing cases for many years with no end in sight.