7 Miles? No problem!

Congrats to star Iowa infection control runners Loreen Herwaldt, Martha Freeman and Marin Schweizer for completing the annual Bix 7 road race in Davenport, Iowa yesterday. Bix for Bix Beiderbecke and 7, well, for 7 miles. 

Contagion

For those of you who didn't get worked over enough by the H1N1 pandemic, there's a movie entitled Contagion that will be released in September. It's about an epidemic of deadly avian influenza and the cast includes some major Hollywood stars. You can see the trailer here. Looks scary--maybe it will increase influenza vaccine compliance!

Hat tip:  Rebekah Moehring

ICHE Special Issue: Antimicrobial Stewardship

Infection Control and Hospital Epidemiology has just announced that it will publish a special issue devoted to antimicrobial stewardship in conjunction with the SHEA spring meeting in Jacksonville, Florida, April 13-16, 2012. 

Topics of interest include:

• Antimicrobial stewardship for special populations, including pediatrics, oncology, hemodialysis, and critical care
• Health outcome and cost effectiveness impact of antimicrobial stewardship
• Use of diagnostic tools and role of microbiology in antimicrobial stewardship
• Effective implementation of programs in community hospitals, long-term care acute care facilities, outpatient settings and non-acute healthcare settings (e.g., dialysis, ambulatory care and ambulatory surgery centers)

Due date: October 1, 2011.

Get writing and submit your paper here.

Call for manuscripts PDF available here.

Good luck!

Oxa-48 KP wreaking havoc

Photo: Wikipedia

According to press releases (here and here), the Maasstad Hospital in Rotterdam, Netherlands, has had 27 deaths due to oxa-48 producing Klebsiella pneumoniae infections over the last 11 months.

Now I am not saying this to be flippant or mean, but here's an example of how having the best MRSA control program in the world doesn't protect patients from other important pathogens. It's one of the most compelling arguments for focusing on practices that impact all organisms transmitted via contact--what we call a horizontal approach to infection prevention. Dan Diekema once said (on NPR, no less), "MRSA's not the only bad bug out there. It's just the most famous."

See you at Starbucks!

There is a very interesting study in the July/August issue of the Annals of Family Medicine from the Medical University of South Carolina (free full text here). Investigators there analyzed data from the 2003-2004 NHANES study, a survey designed to assess the health and nutritional status of the US populace, using an interview and physical examination on approximately 5,000 persons selected as a representative sample of the population. This study also included a nasal swab done on each participant, which found that 1.4% of persons in the sample were colonized with MRSA.

Using the NHANES dataset, the South Carolina  investigators found that persons who drank coffee or hot tea were half as likely to be colonized with MRSA, even when controlling for age, race, socioeconomic status, health status, hospitalization in the last year and antibiotic use in the last month.

Now it's important to remember that this is an observational study, which doesn't allow us to determine causation, as we know that these studies can be plagued by bias and confounding. Nonetheless, the authors do elaborate on the biologic plausibility for their tantalizing finding.

I'm just saying it sure beats squirting mupirocin up your nose!

Trouble in Pittsburgh

The behemoth healthcare system, University of Pittsburgh Medical Center, had its living donor transplant program temporarily shut down after a patient was transplanted with a kidney from a hepatitis C infected donor. The details of the fateful transplant can be found in two well-written articles in the Pittsburgh Post-Gazette (here and here). It's a classic example of the swiss cheese model of complex system failure, where all the holes lined up (in this case the positive lab test was missed on 6 occasions), allowing an adverse outcome to occur. The articles note that UPMC's response was to demote the transplant surgeon and suspend the transplant nurse coordinator. A noted transplant surgeon describes that as an administrator's knee jerk reaction and another stated, "if everyone in transplants got hit for making a mistake, no one would be working." But the journalist probes to unearth how the system fostered the error, and he notes the stresses on the surgeon to increase surgical volume (as well as stressors in his personal life), problems with the electronic medical record, and alarm fatigue. 


I have been intrigued at how physicians who perform the most highly technical procedures in medicine can sometimes be uninterested in details that ultimately can unravel their programs. What infectious diseases physician hasn't been consulted to see a patient who has undergone an amazingly complex surgical procedure, who survived against all odds only due to an enormously talented surgeon, all to be undone by sloppy infection control practices down the line, such as noncompliance with hand hygiene? In the UPMC case, I have to wonder whether a simple tool, such as a checklist, could have prevented this error.

What is your name sir?...Ignaz

Loreen Herwaldt (and thanks to John Boyce) just forwarded along this cinematic depiction of Ignaz Semmelweis and his early investigations into the benefits of hand hygiene. The piece was written/directed by Jim Berry at NYU back in 2001 and funded by a Sloan Foundation grant for scripts featuring positive depictions of scientists. The film is a bit graphic/realistic. 

My favorite quote is from the mother pictured above: "You have a gentle touch sir, I want you to be my baby's namesake. What is your name, sir?"  A: "Ignaz"

Another moving section:  Semmelweis: "I believe that this practice will save lives."  Senior physician: "but this is not our way, at this hospital, doctor, we must be unbending in our practice."

The film is available for viewing on the Sloan Science and Film website (here)

The new ICHE is here, the new ICHE is here!!!

Congrats to all of the authors who had articles published in this August's ICHE. Now that ICHE has a massive new impact score, I suspect most of them now feel like Navin when he says, "Page 73 - Johnson, Navin R.!  - I'm somebody now! Millions of people look at this book everyday! This is the kind of spontaneous publicity - your name in print - that makes people. I'm in print! Things are going to start happening to me now."  Well, I hope all the things that happen to these fine authors are a little more positive.

Highlights:

Page 737, Boyce, John M et al. looked at the impact of an automated mobile UV-C light unit on environmental contamination in 25 rooms after patient discharge. They report the unit significantly reduced aerobic colony counts and C. difficile spores.

Page 743, Rutala, William A et al. wrote an accompanying editorial that concluded that "there is now ample evidence that no-touch systems such as UV-C light or hydrogen peroxide can reduce environmental contamination...(however) only a single study using a before-after design has been published that demonstrated that such a system can reduce healthcare-associated infections." There we go again, hospital infection prevention: the queen (or king) of intermediate outcomes. Would be pretty cool if there were more independent (federal or foundation) resources to study HAI prevention interventions, such as these.

Page 791, Gupta, Kalpana et al. report the results of a cohort of all patients at the VA Boston Health Care System that had clean or clean-contaminated in 2008-2009 and a nasal MRSA PCR test less than 31 days prior to surgery. 6.6% of the patients were MRSA+ and were at significantly higher risk for postoperative MRSA infections (RR, 8.46; 95% CI, 1.70–42.04). Interestingly, vancomycin prophylaxis was associated with higher SSI risk in those negative for nasal MRSA (RR, 4.34; 95% CI, 2.19–8.57) but not in MRSA+ patients.

Page 818, Tohme, Rania A et al. reviewed hepatitis B vaccination rates and immunity among healthcare students during a 10-year period at Emory University. They report that among 4,075 students, only 60% had documented vaccination and 84% had anti-HBs concentration greater than or equal to 10 mIU/mL. It is interesting that despite CDC and ACIP (1995) recommendations of routine vaccination of children aged 11-12 years, and for all less than 18yo in 1999, the majority of students were only recently vaccinated.

If I left you off this list, sorry! You are still awesome!

Dealing with a lot of crap

Here's an interesting video from the Gates Foundation on re-inventing the toilet. As you will see, this has major public health implications. And the video is pretty clever.

Feedback loops! Feedback loops! Feedback loo...

Feedback loop photo from wired.com

Several years ago (yikes!) Dan blogged about 'closing the loop' by providing real time reminders to doctors that their hands are contaminated.  To paraphrase his money quote: "So I think several varieties of feedback will do..It is essential, though, that such feedback be provided as close to the point of care as possible."

There is a very interesting piece in last months Wired that discusses the success of just the type of feedback loops that Dan suggested.  The initial example they give of a successful feedback loop is those real-time dynamic speed displays, or driver feedback signs, that have a speed limit posting coupled with a huge sign announcing “Your Speed.” In this example, speeds fell 14% and were below the speed limit!  I guess you can change behavior.

Could we incorporate such feedback, "as close to the point of care as possible" as Dan suggested, and improve hand hygiene compliance by 14%? Anyway, a very interesting article and they even included a podcast/mp3 that is a good listen.

Source: Thomas Goetz "Harnessing the Power of Feedback Loops" Wired June 2011

Are we closer to a universal flu vaccine?

Eli has blogged before about the potential for a more universal flu vaccine, using conserved epitopes. Last week the same group that previously described a monoclonal antibody targeting a conserved epitope on group 1 influenza A viruses, reported on a second monoclonal antibody that has broad neutralizing activity against group 2 viruses. Both of the antibodies described by this group bind to conserved regions at the base of a hemagglutinin stalk and interfere with fusion of the virus with host cells.

I'm back....

After spending two incredibly intense weeks on the internal medicine wards, I'm back to civilization. With regards to infection prevention, the wards are where the rubber meets the road, so it's always good to see what's happening out in there in actual practice. While it was a grueling two weeks, I had the best team ever, led by Dr. Matt Kappus, shown in the center in the photo below.

VCU Internal Medicine Team 3
Photo courtesy of John Le, M-4 as of today (far left)

CDC goes OOPS!

How does the CDC really feel about infection control?  Perhaps we can get a hint by looking at the cover of their new Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.  How many fundemental breaks with basic infection control do you see? I guess we know there is a new low in minimum expectations!

Oh, by the way, the CDC has just released their new Guide to Infection Prevention for Outpatient Settings.

h/t Jan Kluytmans

Gettin’ “meta” with it!

Talking about bias is so pre-millennial. The kool kids are more interested in metabias. Metabias, by definition, only rears its ugly head when groups of studies are examined. Meta-epidemiological studies (e.g. meta-analyses) can uncover risk factors for bias that don’t seem to be associated with a process active in an individual study. That’s metabias! We’ve blogged about several specific forms of metabias before, including publication bias and citation bias. A new form of metabias is described in this week’s Annals of Internal Medicine: it turns out that single-center trials consistently report larger treatment effects than multicenter trials, even after controlling for sample size and other factors. It’s not clear why this is the case, nor is it possible to determine which study type (single-center or multicenter) gets closer to the “truth” (though I strongly suspect the answer is multicenter). Given that many HAI prevention studies happen to be single center studies, this problem bears further scrutiny…..and a willingness to fund larger (more expensive) multicenter trials.

The case for antimicrobial stewardship: Fluoroquinolone edition

Gobo and Wembly Fraggle deliver fluoroquinolones to the wise Trash Heap

Dan posted yesterday about the scary emergence of ceftriaxone-resistant Neisseria gonorrhoeae. I remember back in my Cleveland medical school days that we were the first in the continental US to lose the ability to treat gonoccocal infections with fluoroquinolones.  I distinctly remember the Sanford Guide recommending against quinolones if the patient had traveled to Asia or Cleveland!  I always thought that was funny.  Here is a quote from an EID article: "In the CDC-sponsored Gonococcal Isolate Surveillance Project in the United States, the frequency of strains with intermediate resistance has increased significantly from 1991 to 1994...the increase in strains with intermediate resistance is associated largely, but not exclusively, with the persistence of such strains in Cleveland, Ohio."

Now we have some more news about fluoroquinolones and again it comes from Cleveland.  Nicole Werner and colleagues reviewed six weeks of fluoroquinolones prescriptions at a city-hospital in Cleveland. The study covered 227 courses in 226 patients (why not exclude the single patient treated twice?) and 1,773 total days of therapy. 70 (31%) or the regimens were deemed unnecessary and fully 690 days (39%) were determined to be unnecessary.

Twenty-seven percent of the regimens were associated with adverse effects -  GI adverse effects (14% of regimens), colonization by resistant pathogens (8%), and Clostridium difficile infection (4%).

I know, it is probably too late to save fluoroquinolones from the trash heap of used-up antibiotics, but when will we ever learn?  Do you think it's time that antimicrobial stewardship programs are finally mandated for all hospitals?  I suspect we will probably have to limit antibiotic prescriptions to ID specialists to have much of an effect.  Many of us have wondered why only oncologists can prescribe chemotherapy while every clinician can go about prescribing antibiotics willy-nilly.  Why do we continue to squander a limited public health resource like antibiotics?  It is not like the findings of this new study are all that surprising - I actually thought it might be worse. Yet 40% of fluoroquinolone-days are wasted and 27% of patients get a side-effect with 4% getting C. diff?? Really? That means for every 25 patients treated, one gets C. diff. How bad does it have to get before we change our system of antibiotic prescriptions? EOR

Werner NL et al BMC Infectious Diseases 2011

Superbug number next...

The gonococcus has now developed high-level ceftriaxone resistance, as described in this abstract from the 19th Biennial Conference of the International Society for Sexually Transmitted Diseases Research. Here also is last week’s MMWR report on emerging cephalosporin resistance in Neisseria gonorrhoeae. The upshot of the CDC recs: treat cefixime failure with the combination of IM ceftriaxone (250 mg) + oral azithromycin (2 gm). Report ceftriaxone treatment failures to CDC and “consult with an infectious diseases expert and CDC regarding re-treatment”. I guess since I’m an “infectious diseases expert” I’d better start thinking about what I’d advise (as the MMWR piece points out, “no other well-studied and effective antibiotic treatment options or combinations currently are available”).

SHEA's Consumer Retort

Kudos to SHEA for publishing a statement on Consumer Reports' article on teaching hospitals and hospital quailty ratings, which include infection prevention metrics. Here's the money quote:

Buried in the methodology, the publisher of Consumer Reports agrees that comparisons must be done carefully, but the article does not reflect this caution. Instead, the article draws broad conclusions about the quality and safety of care throughout entire health systems based on one measurement gathered from a single unit in each hospital.

While Consumer Reports may know how to evaluate refrigerators, they have a long way to go in order to produce a high quality assessment of health care.

Nothing a little duct tape can't fix....

A couple years ago Mike blogged about a simple way to make contact precautions more friendly, involving floor colors that divide the immediate “patient zone” (where gowns and gloves are needed) from a zone in which healthcare workers can communicate with the patient without those barriers. Of course, it costs a bit of money to paint floors or change flooring, so some industrious IPs at Trinity Regional Health System (here in the great Midwest!) decided to take the same approach using red duct tape. They presented their findings at the APIC meeting last week. I’m sure there will be some unintended consequences here (does the duct tape interfere with room disinfection? Will it roll up or buckle and pose a trip-and-fall risk?). Still, I like their willingness to attack this problem with a simple and low-cost solution.

Funding for antibacterial resistance research. Not so much.

At least no funding for ESCKAPE pathogen research

I just got back from attending the World HAI Forum in Annecy and the 1st ICPIC meeting in Geneva.  Both great meetings.  I will share my thoughts on the implications of ICPIC in a later post.

Last year at IDSA, Roy (Trip) Gulick stated that there are now 10,000 possible ART combinations for HIV treatment.  When he said that, I instantly got a sinking feeling in my gut.  Right now, there are many people colonized and infected with resistant bacteria for which we have NO EFFECTIVE THERAPY.  Sorry for shouting.  Think about the MDR-Acinetobacter or NDM-1 strains that are circulating.  Pretty soon we won't even have effective therapy for community UTIs.

As I thought about why this might be, I looked for the federal funding picture for antibacterial resistance research, but there were no published data.  So, we found the numbers ourselves.  I presented the data last week and Marin McKenna kindly described our findings at the World HAI Forum on her Wired Superbug blog.  She did a much better job describing our research findings than I could have.  If you're interested in reading about how much NIH/NIAID spends on antibacterial resistance research, head on over to her blog...

UPDATE:  We published these findings in the first batch of articles in the ARIC journal, see: Kwon et al. 2012 ARIC