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.

Fungal Meningitis Update

It has been a few days since Mike last blogged on this curious but devastating outbreak, and time to mention a few developments. First off, it is now clear that the outbreak isn’t primarily due to Aspergillus, but rather to a little-known soil (or dematiaceious) fungus called Exserohilum rostratum. The Mycology Online site at the University of Adelaide is an excellent quick guide to the gory details of identification (be sure to look carefully for the ellipsoidal to fusiform poroconidia that are formed apically on a sympodially elongating geniculate conidiophore!).

Exserohilum are common environmental molds, and rarely cause human disease. Slow-growing and challenging to identify in the lab, it would be difficult to imagine an agent that would be more insidious and refractory to diagnosis and treatment once injected into an immune-privileged site. This is why the number of cases continues to increase long after the compounding pharmacy responsible for distribution has been shut down (and also why treatment may not be effective by the time a case is recognized).

The CDC website is the best source of authoritative information (as of today, 198 cases and 15 deaths), and this excellent article illustrates the degree to which our CDC and public health colleagues are working to get a handle on this outbreak (a special shout-out to Shawn Lockhart, featured in the photo—Shawn did his clinical microbiology training with us here at Iowa). Those who were exposed to the affected lots of injectable steroids are literally being tracked down one-by-one, using any resources available to state public health authorities (while I was at HICPAC, one public health official described local police knocking on doors to inform those at risk).

Finally, I wanted to highlight the fact that your IDWeek planners have been working overtime to put together a late-breaker session at IDWeek to update all attendees on this outbreak. We will have representation from CDC, a clinical mycologist, and a clinician involved in the care of affected patients. So if you are heading to San Diego please attend!

Does pay for performance in HAI pay off?

The data is piling up suggesting that the CMS policy for nonpayment for HAIs have had little impact on reducing preventable HAIs in acute-care settings. The straw that might break the camel's back is a study in this week's NEJM by Grace Lee and colleagues.  Using a quasi-experimental design and time-series analysis, this AHRQ-funded study looked to see if there was a change in HAI rates after (vs before) the October 2008 nonpayment policy went into effect. 398 NHSN hospital provided data. The results are pretty conclusive: there were no changes in CLABSI, CAUTI or VAP after the implementation of the policy.  In the figures below you can see that things are getting better, just not due to nonpayment.

Of course this is not surprising. Peter McNair published a very nice study in Health Affairs (2009) that estimated that the total financial impact across the entire US would be about $1.1 million annually for six avoidable conditions. When you divide that amount by the number of US hospitals you get...about nothing per hospital. I think CMS might need a bigger stick.

Source: Lee GM et al. NEJM 2012; 367: 1428-37

Infection Prevention During Space Travel

One of the highlights of any conference is chatting with other investigators and hearing about all the creative projects they've been working on.  A perfect example occurred last week in Potsdam when Len Mermel described his multi-year effort to understand infection risks that might arise during prolonged human space travel. Why is this important? Even a short roundtrip to our neighbor Mars might take 400-450 days given that the Mars Curiosity Rover took 254 days to reach the planet's surface. After he described his findings, I was increasingly excited to read the review, and fortunately, I didn't have to wait long, since the pre-print just appeared in CID.

First of all, this is a very well written paper and was a lot of fun to read. He highlights evidence that suggests that microgravity might enhance expression of virulence factors and increase biofilm formation. On the human side, there is evidence that the immune system becomes increasingly dysregulated, which could increase the risk of infections from pathogens such as herpesviruses, and that anaerobic flora in the gut is decreased, which could increase the risk of aerobic pathogens such as Pseudomonas. There is also evidence of enhanced S. aureus skin colonization and Enterobacteriaceae in the upper airways. If that isn't scary enough, microbes have been shown to "survive in free-floating condensate" kinda like what happens in Cleveland or Detroit.

The rest of the paper describes the infection prevention challenges facing the astronauts, what microbial changes to expect and specific issues related to the confines of the spacecraft or habitat. He then thinks ahead by suggesting potential countermeasures that could be implemented using existing vaccines, decolonization therapies and spacecraft modifications designed to minimize risks of transmission. Finally, he lists several important unanswered questions to guide future research.

Excellent work Len!

Source: Leonard A. Mermel, "Infection Prevention and Control During Prolonged Human Space Travel" Clin Infect Dis 2012.

Image Source: Les Bossinas of NASA Lewis Research Center

Chlorhexidine: Also prevents general malaise and existential crises

We can now add Clostridium difficile to the long list of maladies that can be prevented by the zealous application of chlorhexidine (in this study, a 4% aqueous solution, first thrice-weekly and then daily, hospital-wide). Yes, I realize that this study (from our good friends in Nebraska) was quasi-experimental (lacking a concurrent control group), and I realize that it was funded by a manufacturer of chlorhexidine (a company whose name I cannot spell or pronounce).

Potential confounders include changes in diagnostic testing during the course of the study (but these changes should have made a decrease more difficult to detect, because they moved to increasingly sensitive assays), and the introduction of other C. difficile control measures (pre-emptive isolation and bleach disinfection were introduced a couple years before the start of this study, but could have had some delayed impact). Finally, there is the biological plausibility issue—if chlorhexidine isn’t sporicidal, how could it impact C. difficile rates? The authors suggest it could be due to physical removal of spores, and/or to killing of vegetative bacteria or prevention of spore germination. All seem plausible, but require further study.

Chicago Cubs are #1: With the most disgusting ballpark!!!

I've been away for a week, hanging out in Potsdam with some infection control folk and am only now catching up on the terrible outbreaks and important developments that occurred in my absence. One report that must be personally disturbing for our esteemed colleague, microbiologist and favorite Cub's fan Dan is the recent survey of Major League Baseball Stadium cleanliness that found historic Wrigley Field to be the grossest, dirtiest, most vile baseball park ever!  All 30 ballparks were graded on 79 review criteria. Some highlights for the Cubs: 21% hand hygiene compliance in the men's bathrooms - more urinals than sinks apparently and vendors handling food and money with the same hands, Yum!  Hmm, come to think of it, maybe this explains the poor attendance at Wrigley this year?

See the full rankings here.

h/t Mark Vander Weg