Playing Nice: Infection Control and Clinical Microbiology in the Pay-For-Performance Era

As it's probably clear, it's been a great honor for me to work (and blog) with Dan and Mike over the past 8! years. One of the things that stands out when talking shop is their ability to see both sides of an argument even while pushing for the changes they support. Many times, their ability to see both sides clearly is possible because they've lived both sides - Mike has been an ID chief and hospital epidemiologist and is now our CQO and Dan is an ID chief, hospital epidemiologist and clinical microbiologist. You know, if I was a fellow or faculty member looking for a hospital epidemiologist position with great mentorship and support, I would move to Iowa...but I digress.

One specific area where understanding competing goals is critically important is the interplay between the increasing sensitivity and precision of microbiologic tests and the growing pressure to reduce HAI. As you can imagine, with 3% of CMS payments potentially at risk, anything that could impact HAI rates in a negative fashion is bound to be a flashpoint for hospital administrators. With that in mind, I point you to Dan's excellent commentary just published in JCM that examines the implications of advances in microbiological testing on HAI rates and provides specific suggestions for how hospital epi programs and clinical microbiology labs can work together to respond to these changes.

Initially, Dan provides three scenarios where changes in the micro lab could directly impact HAI rates (1) The effect of MALDI-TOF on CLABSI rates (2) The shift from EIA to nucleic-acid amplification tests (NAAT) for C. difficile detection and (3) Pressure to block urine culture ordering to reduce CAUTI. After delving into the current CMS reimbursement landscape, the unintended consequences of improvements in diagnostic testing and the use/misuse of surveillance definitions, he provides six valuable recommendations that clinical microbiology labs (CML) and infection prevention programs (IPP) should consider:

(1) CML leadership should select diagnostic approaches with the goal of improving individual patient outcomes

(2) Hospital and IPP leadership should not pressure the CML to alter diagnostic practices based on the need to demonstrate lower HAI rates for pay-for-performance measures. 

(3) Public health authorities (CDC/NHSN) must be proactive in adjusting HAI metrics to changing CML technology

For recommendations 4-6, you're gonna have to read his commentary. But a hint at #6 -  CML and IPP leadership need to collaborate and advocate for their needs, because, unlike at Iowa, both sides aren't always present in the mind of a single person.

2013 Studies in Memoriam - A Tribute to Studies Almost Lost

Each year the Academy Awards honors those actors and directors who've died in the prior year. It's one of my favorite tributes. Recently, I found myself with a stack of unread journals about four feet high and one of my routines is to clean my office before the start of each year. Thus, I am catching up on what studies I missed or failed to mention when they were first published. This post is a tribute to those studies that have "almost" died in my journal pile...happy holiday reading...

1) I'm particularly embarrassed that we haven't yet mentioned this review written by Dan. He and Michael Pfaller published a review in the June 1 CID on the promise of rapid microbiological detection of MDRO for infection prevention. Sections cover MRSA, VRE and MDR-GNR. What I really like about this review is that it covers the barriers to successful implementation of rapid detection including the "post-analytic" turn-around time and the current dearth of data supporting the clinical utility for many of these approaches. A must read. (NOTE: Currently the CID website is down, I will update with a direct link to the paper once they are back online)

2) Bevin Cohen from Elaine Larson's group at Columbia published a retrospective cohort study in JGIM investigating gender differences in BSI and SSI risk.  The study included three years (2006-2008) of data from a single center. Odds of these HAI were between 15 to 22% lower in women.

3) John Hollingsworth. Sanjay Saint and colleagues from the University of Michigan published a systematic review and meta-analysis of non-infectious complications of indwelling urethral catheters in Annals this past fall. After identifying and reviewing 37 studies they found that minor complications were quite common. For example, urinary leakage ranged from 10.6% in short-term catheterized patients to 52% in those with long-term catheterization. Serious complications were also quite common. If CAUTI isn't reason enough to remove a urinary catheter, these non-infectious complications should be!

4) And to follow up on the urinary catheter removal theme, there was a meta-analysis published in BMJ that quantified the benefits of antibiotic prophylaxis after urinary catheter removal. When analyzing seven controlled studies (5 from surgical patients), they found antibiotic prophylaxis was associated with an absolute risk reduction of 5.8% for UTI and a risk ratio of 0.45. I suspect there are trade-offs in increased antimicrobial resistance that should be assessed before this is more widely adopted.

Credit: James Taylor at the 2010 Academy Awards - one of my favorite tunes

Swabs are evil (and other sage advice from your friendly clinical microbiologist)

The current state of infectious disease diagnostics is an Achilles’ heel to effective treatment and prevention. Despite the strides we’ve made in many areas (molecular diagnostics for viral respiratory pathogens, for example), for many serious infections our turnaround times are too long to be clinically relevant, test performance characteristics are all over the map, and sample acquisition at the bedside, clinic or OR is inconsistent (“whoa, not sure what this is….let’s stick a swab in it and send it to micro…just check all the boxes on that requisition”). One of the most important jobs of a clinical microbiologist is to communicate early and often with clinicians, to advise them on what samples to obtain, and what tests to order, to maximize the likelihood that the correct diagnosis will be made. 

That’s why I’m so happy that a bevy of clinical microbiologists decided to put as much good advice as they could into one helpful guidance document, found here: A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM).

Whether you’re an intern trying to decide what test to order on a patient you suspect of having filariasis, or a neurosurgeon wondering what to do when that focal brain lesion turns out to be filled with pus, this is your handy reference.

Image of E. coli growth from CDC Public Health Image Library

How strong is our first line of detection?

I feel like I should expand on this recent post about why relying upon prompt laboratory detection of CRE carriers is unlikely to help contain spread (aside from during local outbreak responses). Why shouldn’t screening be a pillar of our prevention efforts, particularly given the inspiring stories of local and regional CRE control that utilized screening to detect carriers? Leaving aside the question of how important screening was among multiple simultaneous interventions, these two reports are from academic tertiary care centers with robust on-site laboratory support and external funding to provide financial support for state-of-the-art screening approaches (such as rapid PCR detection of KPC producers).

The sad fact is that this level of clinical microbiology laboratory support is far from the norm. The trend over the past two decades has been toward consolidation and outsourcing of laboratory services, and reducing local resources available for diagnostic microbiology labs. I spoke about this trend, and some of the consequences, at the 5th Decennial conference a few years ago (you can view the slide set here). In the decade that has passed since we noted frequent errors in testing and reporting of blood culture results in a sample of 14 hospital laboratories, I doubt that much has improved. Yes, there are CAP proficiency surveys, but for several reasons these are not good indicators of actual laboratory performance. And while outsourcing microbiology to a regional lab may make short-term financial and technical sense for some hospitals, it also removes lab support further from the front line of patient care and infection prevention, prolongs turnaround times, and comes with a host of pre- and post-analytic problems.

If current fiscal and political trends continue, with additional cuts to public health infrastructure and CDC’s budget, it is difficult to imagine that we can do much in the short term to shore up our surveillance capabilities to respond to the CRE threat.

Meanwhile, thank goodness we’re spending almost $500 million to stockpile a ridiculous amount of a new drug to treat smallpox. I wonder how we might expand our national CRE surveillance and response if each of our state public health departments could focus $10 million on the effort. My head hurts.

Thanks, CDC laboratories!

I am on call this month for our clinical microbiology laboratory, so I spent part of yesterday afternoon squinting through a microscope and scratching my head (yes, at the same time). Another Iowa lab had sent us a slide and was asking our opinion regarding the identity of a parasitic form in section. After conferring briefly with a couple colleagues and our state lab, we sent several images to the CDC DPDx team. They responded less than four hours later (about 9 pm CDC time). In cases like this (which occur all day, every day, at hospitals around the country), patients may never know that CDC laboratorians were directly involved in establishing a diagnosis. And presumably, some of those patients will receive appropriate care based upon a correct diagnosis, and recover enough strength to vote for a candidate who wants to gut the CDC budget.

Read this report, recently submitted to a Senate committee, about the work of the CDC laboratories. Then consider contacting your own legislators to ask them to boost, not cut, essential public health and prevention funding.

Detecting antibiotic resistance is hard!

Eli linked me to this recent Nature commentary on the limitations of current screening tests for certain antibiotic resistant gram-negatives (those that carry carbapenemases). Because the resistance mechanisms for gram-negative bacteria are so complex and varied, resistance detection in the clinical microbiology laboratory has become a huge challenge. Furthermore, even if tests perform well to detect a specific single mechanism of resistance, what about bugs that use combinations of mechanisms? Consider how complicated it turned out to be to refine molecular methods for that comparatively simple organism, MRSA....emergence of empty cassette variants that result in false positives, divergent mecA genes that result in false negatives, and on and on we will go.  Multiply that complexity by a thousand fold for gram-negatives.


What this means is that every clinical microbiology laboratory needs a smart, well-trained clinical microbiologist--to optimize testing strategies, to understand the limitations of currently available methods, and to anticipate and detect problems with shiny new methods.  As the authors of the Nature commentary point out, too many hospitals are trying to cut costs in their microbiology laboratories, including being unwilling to staff them appropriately.  I was asked to talk at SHEA on molecular testing and infection prevention, and covered some of these issues (see below).
SHEA 2012 Diekema