CLSI steps into the MRSA surveillance arena

The Clinical and Laboratory Standards Institute (CLSI) is “a global, nonprofit, standards-developing organization that promotes the development and use of voluntary consensus standards and guidelines within the health care community.” The guidance produced by CLSI is widely respected and adopted as a standard in clinical laboratories. I was interested to see that CLSI has now completed a document devoted almost solely to MRSA screening! See here for sample pages. The document was developed to “provide infection preventionists...with the latest information regarding the development and implementation of a successful MRSA surveillance program.”

Check out the author list on the third page, filled with experts in various aspects of MRSA detection and control.

Now ask yourself these two questions:

How many on the above list are (or have ever been) actual hospital epidemiologists or infection preventionists who do not have blatant conflicts of interest with the makers of rapid MRSA detection tests (e.g. research funding, honoraria, employee)?

I count two (Dr. Salgado, who trained under Barry Farr and is a longtime proponent of active MRSA screening, and Dr. Weber).

How many are employed by companies that produce rapid MRSA detection tests and therefore stand to reap millions from widespread MRSA screening?

I count four, including the Medical Director of Diagnostics at BD-GeneOhm, the Senior Director for Scientific Affairs at Cepheid, the Director of Government Affairs at Cepheid, and a product manager for BD-GeneOhm.

I look forward to reading the full document—I hope it is more balanced than the abstract, which flatly states that active surveillance + contact isolation reduces MRSA transmission (Really? Does it always? Is it necessary?).

ADDENDUM: I reread this post this morning, and realize it comes across perhaps more harshly than I intended. I believe CLSI is a great organization--I am a proud participant on their antifungal susceptibility testing subcommittee. I also understand the need to involve industry in the development of these standards, for several reasons. I further believe that a guide to implementation of an active surveillance program could be quite valuable. Heck, Mike and I wrote one a couple years ago, but didn't focus on the detailed lab issues the CLSI guidance does.

What I meant to convey in my post was the now-pervasive influence of industry in infection prevention. It is simply a fact that diagnostic companies stand to reap great profits from a move to “universal” MRSA screening. This inevitably leads to lobbying for legislative mandates, funding of speakers and “opinion leaders”, and representation on expert panels, etc. This isn’t new, the conflict of interest issue is pervasive in medicine.

You're Fired!

Those are the two words that hospital epidemiologists everywhere wish they could say to non-compliant healthcare workers. At least it's one of my dreams. According to a story in the Philadelphia Inquirer, if you're the lucky infection preventionist at Abingdon Memorial Hospital in Pennsylvania you can actually say that to clinicians that don't wash their hands on room entry and exit. After several years of trying to improve compliance with education and constantly retelling a tragic story of a patient's death from MRSA (the mother of one of the hospital's primary care physicians), they were able to improve hand hygiene compliance from 31% to a plateau of around 80%. With this improvement they report reductions in CLABSI, VAP and SSI but not UTIs.

However, they weren't satisfied. Their new plan is to give index cards to compliant staff that make them eligible for a raffle (carrot). What do non-compliant individuals get? The same cards but with a message that they have one strike against them (stick). If they get three strikes, they will receive a letter that their reappointment is conditional and they might lose their job. It will be interesting to see if compliance improves and if anyone is fired. I suspect the observers may be hesitant to give out that third strike, but I hope not. I also hope my title doesn't infringe a Donald Trump trademark.

Transplantation associated rabies

There's an interesting and disturbing report in Clinical Infectious Diseases that describes the transplantation of organs to six recipients from a donor with undiagnosed rabies. The donor was a 26-year old woman who presented with an encephalitis-like picture and negative testing for the usual causes of encephalitis. Approximately six weeks post-transplant, it was noted that three of the recipients began to exhibit symptoms similar to the donor. Review of archived brain samples from the donor revealed characteristic histopathologic and electron microscopy findings of rabies. Further investigation about the donor revealed that she had traveled to India where she sustained a dog bite. All of the recipients were treated with rabies immune globulin and vaccine. The two cornea recipients underwent explantation of the corneas, did not become ill, never exhibited any virologic evidence of infection, and survived. The liver recipient also remained healthy and had no virologic evidence of infection; however, it is important to note that he had received rabies vaccine 20 years earlier. The other three recipients (lung, kidney, kidney/pancreas) all died of rabies despite aggressive treatment with the Milwaukee protocol.

A few months ago we blogged about two cases of Balamuthia encephalitis transmitted by an organ donor in Mississippi. Since then, at least one of the infected recipients has died. The common theme here is that both the rabies and Balamuthia infected donors died with undiagnosed encephalitides. While I agree with Eli that a complete analysis of the problem is warranted, I don't agree that actions should wait for the conclusions of such analysis. Interim actions should be taken. It seems to me that at a minimum there should be an immediate ban on transplanting organs from donors with undiagnosed encephalitides in cases where transplantation is not immediately life-saving (e.g., cornea, kidney, intestine, pancreas, musculoskeletal grafts). And where transplantation is potentially immediately life-saving (e.g., heart, liver), full disclosure of the donor's diagnosis and its implications should be made available as part of the informed consent process. I suspect that donors with undiagnosed encephalitides comprise a small fraction of the donor pool anyway, though I appreciate the scarcity of organs for transplantation.

Primum non nocere!

Coming soon: more superbug stories!

The IDSA has been sending blast e-mails to members, asking us for stories about patients ravaged by antibiotic resistant bacteria. The idea is to generate contacts that allow reporters to personalize their stories about antimicrobial resistance. Here is an example of the kind of story they want to see, from today’s New York Times.

I think I got a touch of the rabies, doc…..

Check out the MMWR for an amazing story of “abortive” rabies—a 17 year old girl survived rabies, apparently intact, without even requiring ICU care. She didn’t return for her follow up clinic appointment. I assume she headed off to Vegas after her physicians explained to her just how lucky she was…..

MRSA Screening Pro-Con

In January, I promised that I’d post a link to the slides from the “pro-con” session on MRSA screening programs I did with John Jernigan at the Remington Winter Course last week. You can find them here—scroll to Thursday at 5 pm. To view the slides, you have to select “read-only” when the pop-up screen appears. I have another such session at the NARSA meeting in Reston, Virginia on Monday, this time with Lance. A summary of that session can now be found here.

Two things interested me about John’s arguments last week. First, he put a lot of stock in the Staphylococcus aureus antibiogram as one measure of success in MRSA control. I have always felt the “% MRSA” reported in an antibiogram is a very poor measure of disease burden. Which unit would you rather be admitted to: the one with 10 S. aureus infections per month, 3 of which are due to MRSA (“%MRSA” = 30), or the unit with 1 infection per month that happens to be due to MRSA (“%MRSA = 100)? Secondly, he argued that “in-hospital” MRSA infection rates were not a good measure of a hospital’s success in reducing MRSA transmission. So even if a hospital can eradicate MRSA infections from its ICUs, it still might be serving as an “amplifier” of MRSA carriage if it doesn’t implement active screening and isolation. The resulting infections, presumably, have their onset after discharge. The problem with this line of argument is the lack of data suggesting that active MRSA surveillance in the acute care setting prevents “community-onset, healthcare-associated” MRSA disease.

And the winner is...

Last night we were in Washington to see Dick Wenzel receive the Maxwell Finland Award for Scientific Achievement from the National Foundation for Infectious Diseases. This award recognizes scientists who have made outstanding contributions to the understanding of infectious diseases or public health. Criteria for selection include excellence in clinical and/or research activities, participation in the training of future leaders in the field, and positive impact on the health of humankind.

Those of you who know me know that it's really rare for me to even wear a tie let alone a tuxedo! But it was a great time and certainly a well deserved honor for Dick.

                                 Mike Edmond, Dick Wenzel, Gonzalo Bearman