Rats!!! I think you have Tuberculosis

Gambian pouched rat before ID rounds

We recently reported that the WHO endorsed the use of Cepheid's rapid TB test that carries a $17,000 fixed device cost and $17/test cost in developing countries.  The device would cost $64,000 in the US.  In yesterday's NY Times there was an article discussing a recent report in The American Journal of Tropical Medicine and Hygiene by Alan Poling at Western Michigan University that found that the Gambian pouched rat was far better than standard microbiological tests for TB diagnosis. In 10,523 patient, the rats trained to smell the sputum samples found 44% more cases. Sensitivity was reported as 86.6% and specificity was 93%.

Wow.  I hope these results can be validated in other settings.  If these rats are equally or more accurate than standard or rapid TB tests with minimal costs, there is no reason why they would have to be limited to resource-poor settings, right? Compared to a $64k rapid test plus test costs, I bet the rats would be very cost-effective; especially if they are more effective. It would be pretty cool to see ID clinicians carrying 15 pound rats around with them on rounds. 

Poling A. et al AJTMH, December 2010
NY Times article, January 3, 2010

'Tis the data season

After 2 great weeks off, it was back to clinic, and meetings, and all the other stuff. And we've entered into January, my least favorite month. Cold and dark. But there is one thing I do like about January--the stream of data that hits my desk and the review of trends for our annual report. Today I received the hand hygiene data for 2010. Our group captured over 50,000 hand hygiene opportunities last year, a record for us. And our observers did this with the great app, iScrub, created by Phil Polgreen at Iowa. Overall compliance was 92%; 94% for nurses, and 85% for doctors. Not bad!

80% of antibiotics given in US go to animals

Just catching up on things after my long winter nap...  Three weeks ago, FDA reported that 29 millions pounds of antibiotics were used in livestock production in the US.  How does that compare to human use?  A new estimate for human use is 7 million pounds.  Thus, almost 80% of antibiotic use is in food production.  One caveat, it appears this estimate was derived from IMS sales data for selected antibacterial drugs and I'm not sure how accurate those figures are. Early estimates were closer to 70%.

With all of the antibiotic stewardship efforts both in hospital and through education of primary care physicians and patients, you wonder how effective these efforts could possibly be?  If by magic, we could reduce antibiotic exposure in human populations by 50% that would still leave 90% of the actual antibiotic exposure burden untouched.  The funny thing is, bacteria don't care if the antibiotic they are exposed to was ingested by a human or an animal...

link: Maryn McKenna Superbug Blog

Pardon the interruption...

Photo: Society of Robots

There's a front-page article in this morning's New York Times on computer vision systems. The article discusses many different uses of computer vision, such as surveillance monitoring in prisons, but also describes applications in health care. Of interest to those of us in infection prevention is the capability for a computer to watch a healthcare worker interact with a patient and remind him when hand hygiene should have been performed. In the model in use at Bassett Medical Center, when the computer notes a missed opportunity for hand hygiene, it says, "Pardon the interruption. Please wash your hands." So for those hospitals that really want to drive hand hygiene compliance to high levels, here's a new high-tech, Big Brother option.

H1N1 Flu Deaths in the UK on the rise

Per a government report in the BBC and other UK papers, there have been 39 deaths from the flu this winter with 36 confirmed as H1N1-related while the other three were caused by influenza B.  Unlike here in the US, the UK vaccination committee does not recommend a flu "jab" for healthy children less than 5 and other children ages 5 to 15.  All but one of the deaths occurred in people <65yo. Around 20% of all ICU beds in England are now filled with confirmed or suspected influenza patients.

Health Secretary Andrew Lansley said "the people we would wish to vaccinate are people in at-risk groups and over 65s who can be contacted via their GP." Which makes some sense since 23/38 deaths (one patients data wasn't available yet) were from high-risk groups. However, that still leaves 40% of patients without any risk factors. Since there is no vaccine shortage, I wonder why they aren't broadening their vaccine strategy to include younger children. As it is, only 23% of currently eligible children <5 get vaccinated.

The H1N1 virus continues to attack younger children and not older adults. In English children <4yo, the influenza incidence is 184 cases/100,000 while it is only 36 cases/100,000 in those >65yo. An epidemic is defined as an incidence >200 cases/100,000.  Seems like rapid vaccination of children might be a good idea, particularly when you look at the graph below showing 2010-2011 as an active year, similar to the spring of 2008-2009 season when H1N1 began.  If H1N1 vaccine was available in spring 2009, I bet they would have promoted it more than they are promoting the vaccine now.

Oh, Happy New Year!

BBC report (12/30/2010)
Guardian report (1/1/2011)

UK Health Protection Agency Epidemiological Report 30 December 2010

ILI Activity with 2010-11 in red  - taken from UK HPA report (link above)

California's Healthcare Associated Infections Report: For what it's worth...

California has just released its first statewide report on healthcare associated infections (you can view it here). The metrics reported are healthcare associated VRE bloodstream infections per 1,000 inpatient days, healthcare associated MRSA bloodstream infections per 1,000 inpatient days, and CLABSI in ICUs per 1,000 central line days. The report has major problems as evidenced by the disclaimer on every table of rates that says that the data should not be compared between hospitals, which is generally the whole purpose of public reporting. However, since the reporting period for this report ended, the state mandated that all hospitals join NHSN, which they anticipate will improve the quality of the data reported.

Whither the physical exam?

JAMA just posted an online piece about the physical examination of obese patients. The gist is that all of our usual examination techniques are “undermined when the viscera and vasculature are enveloped in a thick layer of adipose tissue.” The authors call for improved training on the adaptation of physical examination to the obese patient.

The physician in me agrees that if the physical exam is of any value, we ought to be better trained to perform it on all patients, obese or not. But the hospital epidemiologist in me asks: how useful is the physical examination, and how often should it be performed in the acute care setting?

Consider what we know about the utility of the physical exam, the efficiency of pathogen transmission by direct contact, and the difficulty of achieving sustained excellence in hand hygiene (not to mention the disinfection of stethoscopes, coats, etc.). Is it wise to encourage multiple potential examiners (medical students, interns, residents, attendings, consulting physician teams, nurses, respiratory therapists) to have such frequent direct contact with acutely ill hospitalized patients?

I have alluded to this issue before, but in the spirit of this blog’s title (controversies), I’ll state the question more directly. Is it time to re-evaluate our physical examination practices in the acute care setting?