Chlorhexidine bathing outside the ICU: Await the ABATE!

Daily chlorhexidine (CHG) bathing has become routine in many ICUs. Given that more healthcare-associated infections (HAIs) (including more central-line associated bloodstream infections (CLABSIs)) occur outside of the ICU, many hospitals have also implemented this practice on general medicine and surgical wards. However, to this point there are few data to support the effectiveness of CHG bathing outside of ICUs. 

So I was very excited to hear Susan Huang present the results of the Active Bathing to Eliminate Infection (ABATE) study at IDWeek last week. Similar to the REDUCE MRSA study, this 53 hospital cluster-randomized trial took place in the Hospital Corporation of America (HCA) system. Units were randomized to routine care or decolonization (this consisted of daily CHG [4% rinse-off shower or 2% leave-on bed bath] with addition of mupirocin nasal ointment for 5 days if + for MRSA by history or culture/screen) for a 21-month intervention period (after collecting baseline data for 12 months). The primary outcome was MRSA or VRE clinical isolates, and the main secondary outcome was any bloodstream isolate attributed to the unit (for common commensals, 2 or more + cultures).

With the requisite reminder that it is always best to wait for the peer-reviewed publication to make firm conclusions, the results presented at IDWeek suggest the likely take-home from this study: No measurable benefit in the entire population, but significant reductions in MRSA/VRE clinical cultures and bloodstream infection in the subgroup with devices (central lines, midlines, and lumbar drains). This subgroup represented 12% of the study population but accounted for 34% of all MRSA/VRE events and 59% of bloodstream infections. The additional reductions in the decolonization arm for this subgroup (compared with routine care) were 32% for MRSA/VRE cultures and 28% for BSI (both highly statistically significant). 

Once published, these findings will leave infection prevention programs with some interesting decisions. A quick take might be, “OK, let’s just use CHG in those non-ICU patients with devices (or just central lines).” However, this isn’t what the ABATE trial evaluated—it showed a substantial reduction in MRSA/VRE/BSI outcomes in patients with devices when everyone else was also receiving CHG (+/- mupirocin). To assume that the decolonization of the non-device population had no beneficial effect on those with devices is to discount any potential role for reduction in pathogen transmission between non-device and device patients. Another tricky question has to do with the role of mupirocin—adding this agent to CHG for known MRSA carriers without knowing how important this component of the intervention was adds some logistical complexity, cost, and antimicrobial resistance concerns (the investigators are also doing the microbiology work to assess for CHG and mupirocin resistance emergence). 

We’ll revisit this study once it is published and all the details are available. For now we should congratulate Susan and the entire ABATE trial team for another tremendous contribution!

IDSA response: Guest post by Dr. Dan McQuillen

The following is a guest post from Dr. Daniel McQuillen, IDSA Chair for the IDWeek 2016 Program Committee, and President of the Massachusetts Infectious Diseases Society.

With the acknowledgement that IDSA needs to expand communication/marketing efforts in this area, I wanted to offer some information on ongoing activities our society has been engaged in for several years, beginning with IDSA’s leadership level membership in the Cognitive Care Alliance, an organization that has evolved from a loose coalition to a more formal structure last January. The Alliance hopes to take advantage of the collective power and footprint of cognitive specialties to advance the agenda that the current payment system seriously undervalues cognitive services. Change is slow and incremental in this area, but some of the reforms in payment delivery coming along offer opportunities for ID to improve our reimbursement position in the clinical arena and more importantly in the non-clinical arena (antibiotic stewardship programs (ASP), infection prevention (IP), overall system quality). You'll note that the Alliance member who signed this letter to the Senate Finance Committee (John Goodson from SGIM) is also the author of the recent NEJM article regarding fixing the Medicare Fee Schedule.

IDSA representatives to the AMA CPT/RUC committees have been involved in development and valuation of codes for physician supervision of OPAT infusion, RVU revaluation (upwards) of Evaluation & Management codes and transitional/continuing care codes. In addition, the IDSA Board approved a partnership between the Valuation Workgroup that I lead and The Advisory Board, a consulting group with a healthcare focus, to formally develop the concept of an ID Hospital Efficiency Improvement Program. Such a program will contain ID service lines that are threads throughout healthcare systems, and can serve as templates for members to use when they are proposing new or expanded ASP, IP and OPAT programs to their hospitals or systems. The IDSA Board of Directors previously funded our work with an external expert valuation firm to establish that the benchmarks for “fair market value (FMV)” for ID executive compensation should be higher than the FMV numbers usually thrown out by hospital executives at ID docs. The compensation survey just published by the IDSA Clinical Affairs Committee (CAC) complements this and represents an effort to generate accurate data to counter the inaccurate data promulgated by MGMA and Medscape, not a ‘spin’ that everything is fine. It is just one piece of a broad effort to bolster the value of ID specialists to the systems they work in and support. I note that SHEA has recently surveyed its membership on compensation and await a report on the findings in hopes that it serves as another more accurate benchmark reference. The FMV data along with examples of medical executive co-management agreements for non-clinical activities with sample contracts can be found in the “Value of ID Specialists Toolkit” on the IDSA website (membership login required).

A major thrust of what the IDSA Clinical Affairs Committee, Value Task Force, and Valuation Workgroup have been doing for several years is to establish a robust set of tools with supporting evidence that will serve to increase the benchmarks for what we get paid for our non-patient care activities. New trainees coming out of fellowship have little idea how to establish the value of and negotiate for fair compensation for those activities (I know I had no clue). Success in these efforts will go a long way to increasing overall compensation and have potential to yield far more reward than increasing payments for E&M services would. Our specialty’s inherent altruistic nature, especially in academic settings but still in many clinical practice settings, gives our expertise away with too much ease. We have to change that.

Finally, two IDWeek plugs: the IDSA CAC has organized a session for several years that explores the issues of Health Care Reform as they affect our specialty. This year will feature talks on Health Care Reform trends by a speaker from The Advisory Board, ID-led ASP, and how ID specialists fit in a bundled payment environment. Second, in lieu of their annual Business Meetings, the Presidents of IDSA and HIVMA will be hosting an ID “State of the Specialty” Town Hall Meeting Friday evening at IDWeek. Please attend with suggestions in hand.

Do you have a question?

IDWeek abstract dispositions were just emailed last week. Hopefully you received good news and have already started planning your trip to Philadelphia! IDweek discounted registration closes July 25th.

For those also attending SHEA2015 in Orlando, this will be the first SHEA meeting in three years where we will be accepting abstracts (kinda like the old days but with competitions, voting and awards). So get busy making science - abstract submission closes January 16, 2015.

Whether you are attending IDWeek, SHEA or both meetings, I thought a quick review of Q&A etiquette was in order. I've pasted an algorithm to follow when you're thinking of asking a question at either meeting. These questions are particularly important to follow if you're thinking about asking a question during a University of Iowa student presentation. Thanks!

source: this diagram has been all over twitter the past two months. I have no idea who to thank or where to give attribution. If anyone knows, please comment and I will update the post. 

IDWeek 2013: Media, Social Media, and Open Access

One of the great things about sitting on the planning committee of a national meeting is the ability to put together sessions that are a bit "outside the box" if you will.  During the planning of IDWeek 2013, I had the opportunity to attend the ScienceOnline2013 Conference in Raleigh where I reconnected with Maryn McKenna and met Jonathan Eisen. I thought that many of the concepts that the science journalists (McKenna) and scientists (Eisen and Smith) discussed at ScienceOnline were directly applicable and perhaps urgently needed by the public health community that attends IDWeek. Specifically, I felt that public health was a little too heavy on the "health" and a little too light on the "public." So I worked with my colleagues on the planning committee, including Scott Fridkin and Dan Diekema, to craft a session that focused on three major methods for selling public health science to the public.

The first important topic was open-access publication. If the public and journalists don't have access to your science because it's buried behind a paywall, then it doesn't even exist.  The second topic was social media, which is a method by which scientists and public health practitioners can communicate their science or policies directly to the public including science journalists. Finally, we needed a speaker to help explain how best to interact with journalists to communicate our science and messages. So, we were very lucky to have Jonathan Eisen, Tara Smith and Maryn McKenna speak at our session at IDWeek earlier this month in San Francisco.

There are several sources available for those of you interested in the session's content:

Jonathan Eisen wrote a nice post describing the entire session and also created a Storify (a collection of live tweets associated with the session) covering all three talks, both of which you can read here at one of his blogs. He's also posted his slides on slideshare.

Tara Smith posted her slides on social media at Figshare. She also posted the slides from her excellent S. aureus in animals talk, which you can access through her blog.

Guest Post: IDWeek in Review

This is a special guest post by Dan Morgan, MD MS. He's an assistant professor at the University of Maryland, Baltimore.

After a hectic few days of conferencing at IDWeek I’m looking forward to my more hermit-like routine. Although fields of knowledge tend to advance relatively slowly, this IDWeek was inspiring for a number of interesting ideas emerging in hospital epidemiology. Although I'm sure I missed most of what happened while I was talking in the hallways or waiting in the lunch line, I'm still mulling over a few ideas on flights back to the East Coast that I would like to share.

Antimicrobial-resistance is increasing. This is a worldwide phenomenon in which what happens in one country affects other countries. This is an issue in the hospital with carbapenem-resistant enterobacteriaceae and Acinetobacter and although declining, MRSA is still a large problem. The community also is critical, holding a huge burden of resistance not only in MRSA but gonorrhea and other sexually transmitted infections, along with other pathogens like malaria and TB.

Manipulation of the microbiome is beginning to be seen as a therapeutic target. The remarkable experience with fecal transplants was frequently mentioned and a neater, cleaner method for taking a pill containing poop to populate the colonic microbiome is under evaluation in an ongoing trial in Canada from Thomas Louie at colleagues. Beyond C. difficile, nasal MRSA decolonization through microbiome manipulation was discussed by Mary-Claire Roghmann and the exploratory papers on obesity and other non-infectious diseases was reviewed by Bob Weinstein.

Public policies to promote HAI prevention were hailed as a success in a video presentation from Denise Cardo, and regardless of ones perspective, as stated by David Calfee and Brad Spellberg, public reporting of process measures and outcomes is here to stay.

Infection prevention outside the hospital was highlighted in multiple sessions. From debates on contact precautions in nursing homes, interventional studies by Lona Moody showing a benefit secondary to improved attention to standard infection control in long-term care facilities, and Mary Hayden's presentation on a bundle to prevent CRE in LTACHs.

Methodology of infection prevention studies is improving. Multiple cluster trials were discussed (those above by Mary and Lona and the BUGG study by Anthony Harris—full disclosure, I was a co-author with Anthony on this study) and methods to perform more rigorous quasi-experimental and pragmatic studies were well described by Jessina McGregor, Ebb Lautenbach and Marin Schweitzer in an advanced epidemiological session.

Technology is improving but several technologies (e.g interventions for room cleaning (Curtis Donskey) or hand hygiene (Kal Gupta)). However, when they are ready for prime time they will need to be integrated appropriately as one part of healthcare epidemiology.

Chlorhexidine patient bathing is the new black. After recent NEJM papers by Susan Huang, Mike Climo (and most other luminaries in healthcare epidemiology) there seems to be a move towards widespread adoption in the United States. At IDWeek, CHG was also presented as potentially beneficial for CRE prevention in LTACHs and despite nervousness around FDA warnings, is being used in NICUs. Some expressed concern for the possibility for future decreasing susceptibility to CHG.

Shutdowns have an effect! A power outage on Saturday ended some sessions early but the more remarkable shutdown was federal. Notable were the absences of organizer Scott Fridkin and many leaders who work for the CDC or VA. The rapture realized!

Thanks Jenn!

As we alluded to previously, the inaugural IDWeek was a success.

Sadly, one of the people instrumental in making it a success is leaving the Society for Healthcare Epidemiology of America (SHEA). As Executive Director, Jennifer Bright, MPA, has led SHEA through a period of unprecedented growth. 

A partial list of SHEA milestones under her direction were outlined in the e-mail announcement of her departure, and include: (1) successful introduction of a new SHEA Spring educational and research conference, (2) the inaugural IDWeek, (3) establishment of the SHEA Education and Research Foundation, (4) establishment of the SHEA Research Network, (5) introduction of the Antimicrobial Stewardship in Practice online course, (6) development and implementation of regional HAI training courses, (7) successful ACCME reaccreditation, (8) the SHEA International Ambassador Program, (9) roll-out of the SHEA young investigator epi-project competition and awards, (10) partnership with Medscape, (11) several years of increasingly successful annual meetings, including the 5th Decennial International Conference on HAIs, and (12) a steady increase in SHEA membership. 

In our opinion, Jenn was the most successful executive director in SHEA’s history. We will miss her personally, and SHEA will miss her guidance. Good luck in the future, Jenn!

The boiling frog and antibacterial resistance

I just returned from IDWeek in San Diego (as many of you have). I will say that it wasn't the same as having a standalone SHEA meeting - fewer impromptu hotel lobby discussions and few Europeans - but it had its moments. For one, the sessions were better attended - I think many ID physicians who would normally not travel to a spring SHEA meeting, wandered into infection prevention sessions. Perhaps they direct the infection control committee at their hospital and wanted an update. It was also interesting to see the community protesters out in force; we don't get that kind of attention in infection prevention...but perhaps we should.

The Lyme disease guideline protesters did get me thinking about community action and infection control and why we don't get that kind of attention.  The early nineties saw plenty of HIV/AIDS protests and now that MRSA alone is associated with similar mortality (imagine if you add MSSA, VRE, KPC, NDM-1, ESBL, MDR-acinetobacter), I wondered if and when the public and clinicians would wake up to a world without antibiotics and get angry.  I know there are differences between the HIV and MDRO epidemics. Yes, HIV is a single virus that struck young people down in the prime of their lives, but with MDROs we're facing a world with unsafe surgery (or no surgery), death during neutropenic fever and perhaps fewer transplants. So why is there such a huge difference in our responses?

I think a major reason that MDROs attract little attention is that the emergence of resistance occurs too gradually. A useful metaphor in this case is the boiling frog.  The story goes that if you place a frog in boiling water, it will immediately jump out, but if you place it in cool water and slowly turn up the heat, it will be boiled alive. Since carbapenem-resistance Gram-negatives didn't just appear one day like HIV, we see less response to the problem. We had penicillins to protect us and when they failed we had cephalosporins and then when they failed we had the carbapenems. The problem is, we stopped investing in antibiotic discovery 30 years ago, and there is nothing after carbapenems. So now, we must wait 10-20 years for new antibiotics and we MUST invest in infection prevention research and implementation. I think MDROs are due for a protest movement, but it probably won't appear. We all love a good warm bath, now don't we.

IDWeek!

It has been a great IDWeek so far, with almost 7000 registered attendees.  I've moderated and attended several excellent sessions that we'll be blogging on next week, when we have a few minutes to absorb it all!  Susan Huang's presentation of the REDUCE MRSA trial results occurred today, so we'll no doubt be discussing how these data further support Mike's long contention that horizontal infection prevention strategies are superior for MRSA control. Yesterday we received an excellent update on the fungal meningitis outbreak from Tom Chiller, Carol Kauffman and Tom Patterson.  Carol and Tom also just coauthored (with Pete Pappas) this summary from today's NEJM, check it out!   

Happy Global Handwashing Day!!

Hey everybody!  Break out the soap and water and clap those soapy hands together as we celebrate the 5th anniversary of Global Handwashing Day! October 15, 2012

 

And if you're heading to IDWeek in San Diego, come to session #5, a symposia titled: "Hand Hygiene, State-of-the-art: Surveillance and Compliance" where I will be moderating and the good Dr. Edmond will be speaking about creative ways to improve hand hygiene. Other speakers include Dinah Gould, Phil Polgreen and Kate Ellingson.  Should be a great sesssion.

The depredations of the Staphylococcus

From: Public Health Image Library

“Among the more chastening chapters in the annals of microbiological research is the story of our apparently dismal failure to control the depredations of the staphylococcus.”

The above quote, by Canadian microbiologist Claude Dolman, remains as true today as when he wrote it in 1955. Each time I attend on our busy ID consult service, I’m astonished again at how very nasty, and how very common, is S. aureus. Earlier this week we saw a patient with a confusing clinical presentation (confusing to me, anyway). At the end of the day, as we were going back over plausible etiologies for his symptoms, I said, “it’ll probably end up being just another presentation of invasive S. aureus disease”. As I was saying those words, his admission blood cultures were turning positive for….yes, S. aureus (in this case, methicillin-susceptible S. aureus). At any given time, I’d say about half the patients on our consult service have invasive S. aureus disease (evenly divided between community-acquired and “community-onset healthcare-associated”).

If you type “aureus” into the IDWeek online program planner, you’ll get 170 matches. That’s a lot of learnin’ you could do about S. aureus epidemiology, diagnosis, treatment and prevention! So if you haven’t yet signed up, please join us next month in San Diego.

IDWeek and Social Media

Note: This isn't meant to offend - I post this because I genuinely want to see this meeting succeed and worry that we are missing tremendous opportunities to advance our cause(s)

For the past year, I've been suggesting through discussions and emails that SHEA and IDWeek could utilize social media to engage scientists and the public. I've even written about the importance of marketing your science earlier this year. So far, nothing has happened. For example, I just reviewed the number of twitter followers of SHEA (171) and IDWeek (57).  If you look at APIC (1,163 followers) + AJIC (362), ASM (2,816) and IDSA (1,749) they do much better. That is, someone seems to care about social media...

How can a huge meeting with expected attendance of >5,000 have only 57 followers, only follow 5 "people" and have 28 total tweets (close to zero about science)? It's because they don't take it seriously. If I had submitted an abstract and it was selected as a poster or podium presentation, I would want the meeting to advertise my science to a huge group of attendees and science journalists, but IDWeek has been close to useless on that front so far. There have been numerous times that authors, attendees and our blog have mentioned IDWeek in a tweet or blog post and there have been almost zero retweets, zero follows and zero interaction. If the meeting is not engaged in the science and its promotion, why should I submit my science to IDWeek? What do I get out of it?

We have 8 weeks or so to the meeting - there's still some time, but it's running out. Let's step it up IDWeek.

EOR

Should I accept this abstract?

I’ve been reviewing scientific abstracts for IDWeek, which is how I know that there is going to be a lot of excellent work presented there—if you haven’t registered, do so now!

During my review, I ran across the very succinct abstract below (I’m not making this up).

I suspect this one might not make the cut (we require a more detailed data summary). Sadly, it does sum up quite a lot of the hospital infection prevention literature.  On a positive note, what makes much of the work being presented in San Diego worth hearing is the slow but steady progress our discipline is making in study design and analysis.

ESCMID-SHEA Training Course: Potsdam 1-4 October

Looks like it's going to be a busy fall.  In addition to IDWeek (October 17-21), ICAAC (Sept 9-12), SMDM (October 17-20), there is the annual ESCMID-SHEA Training Course in Hospital Epidemiology in Potsdam, Germany.

The course is made up of 3 modules: the Healthcare-associated Infection Prevention and Management Core Module, the Applied Infection Control Module and the Healthcare-associated Infection Advanced Epidemiology Module. Course fees are 1290 Euro for Society members, which includes hotel and food. Of note, 1290 Euro = $1721.2470 US if you sign up...exactly.......now!  Oh, shucks, too late it just changed.

Update: 28 March at 1pm CT: Cost is now $1715.57

The course coordinators are Marc Bonten, Bart Gordts, Jan Kluytmans, Leonard Mermel and Andreas Voss. The course faculty spans the globe with five faculty from The Netherlands and two faculty from The Iowa.  Sign up now!

• Marc J. M. Bonten, Utrecht, The Netherlands
• Ben Cooper, Oxford, UK
• Markus Dettenkofer, Freiburg, Germany
• Bart Gordts, Antwerpen, Brussel
• Loreen Herwaldt, The Iowa, USA
• Arno Hoes, Utrecht, The Netherlands
• Jan Kluytmans, Breda, The Netherlands
• Leonard Mermel, Rhode Island, USA
• Eli N. Perencevich, The Iowa, USA
• Evelina Tacconelli, Rome, Italy
• Christina Vandenbroucke-Grauls, Amsterdam, The Netherlands
• Andreas Voss, Nijmegen, The Netherlands
• Andreas F. Widmer, Basel, Switzerland

Submit your work to IDWeek!

Although the abstract deadline for IDWeek is still 2 months away, it is not too early to decide what work you wish to submit for presentation in San Diego in October. The abstract submission site is open until May 11, 2012 for regular submissions and until August 10, 2012 for late breakers.

IDWeek Rejected Session

Dan and I are in DC today for the IDWeek Program Planning Committee meeting. Of course, we can't discuss actual sessions, so I thought of a fake session to get you excited for the 2012 joint meeting.

Session Title: Infectious Disease Issues on Sesame Street

Stop Blaming the Birds: From West Nile to Avian Flu - speaker: Big Bird

Risk factors for "Red Man Syndrome" - speaker: Elmo

Salmonella Typhimurium and Water Frogs - speaker: Kermit the Frog

Y. pestis or Francisella tularensis in Prairie Dogs - speaker: Prairie Dawn