And now for something completely different...

I posted back in October about some “microtargeting” of the chronic Lyme disease vote in Virginia, and in the comment section I referenced a short New Yorker blog post by Michael Specter. In a recent interview on NPR, Mr. Specter noted that he got “about 207 million pieces of hate mail” after that post, such an astonishing response that he convinced his editors that he should do a longer piece on the topic. 

That piece, “Lyme Wars”, is in this week’s New Yorker and is well worth a read.

More dirty laundry......

A new study in the American Journal of Infection Control by Dr. Silvia Munoz-Price and her team at the University of Miami provides additional insights on laundering of clothing worn in the clinical setting. In a convenience sample of 160 physicians and medical students, the Miami team found that white coats were laundered on average every 12.4 days, while scrubs were laundered every 1.7 days. I found it a little surprising that for scrubs the frequency wasn't closer to 1.0, but that's tremendously better than 12 days! For both coats and scrubs, faculty laundered their attire more often than housestaff or students. Interestingly, the major reasons given for wearing white coats were: (1) ego (makes me looks and feel like a doctor, 29%), and (2) storage needs (25%). Neither is a good reason.

Late last year, the same team published a study that found that white coats were more commonly contaminated with pathogens than were scrubs in the ICU setting. Moreover, if the hands were contaminated with a pathogen, white coats were more commonly contaminated than were scrubs. And all of the HCWs with negative hand cultures were dressed in scrubs.

Both studies were relatively small and performed in a single (though very large) medical center. Nonetheless, there is a body of evidence accumulating that clothing contamination in the clinical setting is a real phenomenon and probably should no longer be ignored by infection prevention programs. So I was delighted a few days ago to see that West Virginia University Hospitals is considering banning ties and white coats.

Photo:  Dr. Munoz-Price (far right), in scrubs!

VRSA - First Case in Europe

Lost among the attention given to MERS in the recent NEJM and the H7N9 papers published in the Lancet today is a report of the first vancomycin-resistant S. aureus case in Europe. 

The case was in a 74yo in Portugal with diabetes on dialysis. She had prior pseudomonal and MRSA diabetic foot infections treated with vancomycin. This May she had VRSA detected in pus from a toe amputation wound with MIC for vancomycin of >256 μg/mL and MIC of 24μg/mL for teicoplanin. VRE and P. aeruginosa were also cultured. The VRSA strain was sequence type ST105, SCCmec type II, and had both the mecA and vanA genes (from her VRE). This VRSA was resistant to erythromycin, clindamycin, gentamicin, and ciprofloxacin, and susceptible to co-trimoxazole, tetracycline, tygecycline, linezolid, daptomycin, quinupristin/dalfopristin, fusidic acid, cloramphenicol, rifampicin, and mupirocin.

A bundled intervention to decrease surgical site infections: A Video Abstract

Last week we discussed a recent BMJ meta-analysis of SSI prevention intervention studies in cardiac and orthopedic surgery. Who better to tell you about the important results than the authors themselves. Loreen Herwaldt and Marin Schweizer offer their thoughts. Enjoy!

The In(patients) and Out(patients) of Antimicrobial Stewardship

I've been lucky enough to attend the 4th World HAI Forum on Antimicrobial Resistance this week in Annecy. This morning's excellent session on antimicrobial stewardship was chaired by Stephan Harbarth and Herman Goossens and brought to light many barriers to the wider adoption of stewardship by non-ID physicians. For one, the accuracy and economics of rapid diagnostics and algorithms were identified as a major barrier. In particular the negative predictive value, which would allow primary care physicians to stop (or not start) antibiotics, was suggested as a key target.

Another, brought forth by Kent Sepkowitz, was that the whole enterprise of "stewardship" lacks a main outcome measure or at least has transitioned from Decreasing Antimicrobial Resistance, to decreasing costs, shortening length of stay, educating the next generation of clinicians, and finally easing workload for ID specialists and trainees. He suggested that presenting stewardship as a patient safety issue with a primary target of drug resistance rates in key indicator organisms will bring greater rewards. Tom Gottlieb responded that the burden should be on the others to prove that stewardship doesn't work since antibiotics are such a limited resource. Bob Wachter implied that a key "bias" against stewardship in the US is that compared to the patient safety movement, which targets the individual patient as the beneficiary, stewardship benefits "others." Loreen Herwaldt said that a microbiome outcome could provide an individually-focused patient safety target.

Of course, I can't even begin to transcribe and communicate all of the excellent points made by the attendees. Fortunately, two interesting studies were published in the past 2 weeks that examined the impact of stewardship interventions in the outpatient and inpatient settings.

The first study by Jeffrey Gerber and colleagues in JAMA described an outpatient cluster-randomized trial in 18 pediatric practices. They examined prescriptions for acute respiratory infections 20 months before and 12 months after the intervention, which included one 1-hour on-site clinician education session followed by 1 year of personalized, quarterly audit and feedback of prescribing. Prescription of broad-spectrum antibiotics decreased by 6.7% more in the intervention practices compared to usual practice clinics, while off-guideline prescribing decreased by 10.7% more for pneumonia and 14% more for sinusitis. Evidence supporting the public health benefits (i.e. reduced resistance) of this intervention are not described in the paper.  In fact, the word "resistance" appears only once in the entire article.

The second study by Greg Filice and colleagues at the Minneapolis VA examined the impact of an inpatient computer decision support system for antimicrobials on appropriateness of antimicrobial prescriptions in a retrospective cohort. The system was associated with a higher level of appropriate prescribing, 44% vs 33%. However, the most interesting finding was that the most important factor influencing prescribing was the accuracy of the initial diagnosis.  If the diagnosis was correct, prescribing was appropriate 62% of the time compared to only 11% when the diagnosis was incorrect or uncertain. Thus, unless we can help clinicians with their diagnostic accuracy, we will have a limited impact on antibiotic prescribing.

ok, back to the meeting for me...

Take a 3 minute break to watch this video....

Hat tip: Susan Peloquin

A pleasant surprise....

Yesterday, the FDA quietly posted an announcement regarding the requirement for submitting an investigational new drug (IND) application by physicians who perform fecal transplantation. In part, it says:

Some health care providers have stated that applying IND requirements will make FMT unavailable and have suggested that an alternative regulatory approach is needed to ensure the widespread availability of FMT for individuals with C. difficile infection unresponsive to standard therapies. 

The agency acknowledges these concerns and intends to exercise enforcement discretion regarding the IND requirements for the use of FMT to treat C. difficile infection not responding to standard therapies provided the treating physician obtains adequate informed consent from the patient or his or her legally authorized representative for the use of FMT products. Informed consent should include at a minimum, a statement that the use of FMT products to treat C. difficile is investigational and a discussion of its potential risks. 

FDA intends to exercise this discretion while the agency develops appropriate policies for the study and use of FMT products under IND. The agency intends to issue guidance reflecting the agency’s intention to exercise enforcement discretion.

During this time FDA strongly encourages compliance with the IND regulations, and stands ready to work with sponsors who are interested in conducting clinical trials.

I've read this a couple of times, and I'm not sure exactly what this means. Can fecal transplantation now be performed without an IND as long as there is informed consent? It sounds as though further information is forthcoming. Nonetheless, it appears to be a step in the right direction. Kudos to the patients and their families for making their voices heard. Yesterday, one of my patients spoke about her experience here:

NBC12.com - Richmond, VA News