Please, please don't try this at home!

Today, I ran across a letter in the American Journal of Infection Control that left me nearly apoplectic. In the letter, the authors argue that nonhospitalized patients with C. difficile infection should be on contact precautions while AT HOME! Let's think this through this, people. Are we going to confine an elderly person to their bedroom, and wear gowns and gloves when we walk into that room? If grandma eats dinner with the family are they all going to sit at the table wrapped in plastic? What about Fluffy the cat? Gowns and gloves for her, too?

There's actually an excellent population-based study that evaluated the risk of infection in household contacts. Over 2,000 C. difficile index cases were evaluated, and the risk of infection in household contacts was 0.4%. Let's use some common sense: if the infected person can have their own bathroom that would be great, clean the bathroom with bleach, and practice good hand hygiene. But for God's sake, let's not make it a leprosarium.

Prevention, anyone?

Thanks to Eli’s recommendation, I watched the Frontline documentary on antimicrobial resistance last night. The culprits (MRSA, pan-resistant Stenotrophomonas, NDM- and KPC-producers) are fearsome, and the stories are riveting. The most haunting line is exactly ten minutes in, when Will Lyman (the somber voice of Frontline) intones that “Addy and her mother had entered the post-antibiotic era”. The statement is both shocking and true, and one we’ve covered before. Overall, this is perhaps the best lay media treatment of this issue that I’ve seen, and features many of our eloquent friends and colleagues. In particular, pay attention to Dr. John Quinn, an expert in gram negative resistance who died earlier this month after a battle with cancer. He will be sorely missed. You can watch the documentary in full here. 

One minor criticism: too much emphasis on drug development and new technology (e.g. whole genome sequencing, “robot” cleaning), not enough discussion of the hard work of basic infection prevention (hand hygiene, contact precautions, environmental cleaning). I know from discussion with those involved that these topics were discussed during interviews, but probably not deemed compelling enough to survive the editing process. New drugs buy some time and can be life-saving, but only until bacteria catch up…..and genome sequencing didn’t halt the NIH outbreak, strict enforcement of basic prevention measures did. I hear a lot of general nihilism about hand hygiene (adherence rates will never exceed 60%, high rates can never be sustained, etc., etc.). The truth is that we have much more work to do to better understand and solve the hand hygiene problem. 

Frontline plans a second show in the spring of 2014 that covers the role of antimicrobial use in driving resistance, which I look forward to seeing. Might I suggest they begin planning a third installment, dedicated exclusively to the problem of hand hygiene in healthcare settings?

Photo of Ignaz Semmelweis from Wikipedia Commons

NIGHTMARE BACTERIA coming to your PBS station October 22nd!

It's not quite the Zombie Apocalypse, but these carbepenem-resistant nightmare bacteria are clearly the next scariest thing. PBS's Frontline seems to think so. Producer/Writer/Director Rick Young has pulled together a 1-hour investigation into antibacterial resistant infections including (it appears) NDM-1 and the NIH CRE outbreak. From the promotional material it also seems that the program will touch on the lack of investment in drug discovery in addition to excess use, as causes of the epidemic. Remember, check your local listings.

CAUTI SCHMAUTI ! (part 2)

I recently blogged about about the big project to reduce UTIs that, well, wasn't all that effective. It reduced CAUTIs by 0.41 infections/1,000 catheter days. This seemed to me to be a high-burden, low-impact intervention. But wait, there's more....

The November issue of Infection Control and Hospital Epidemiology has a retrospective cohort study by investigators at Baylor University. Over a 9-month period they examined all cases of positive urine cultures occurring in the presence of a urinary catheter in 5 medical wards and 5 extended care wards. This yielded 308 patients with catheter-associated bacteriuria. They went on to subclassify cases as CAUTIs and performed a 30-day follow-up. They found 2 cases of secondary bloodstream infection in the 128 CAUTI cases identified (1.6%). They cite a prior study by Dennis Maki that found 1 secondary BSI in 235 cases of CAUTI (0.4%). Now it's important to remember that the primary reason we are interested in CAUTI is the risk of secondary BSI because that's where we have the serious morbidity and mortality.

So let's to try to put this into perspective. We'll look at the worst case scenario first (i.e., we'll use the pre-intervention CUSP rate of infection [2.55 CAUTI/1,000 catheter days] and we'll use the Baylor risk of secondary BSI [1.6%]. If I apply these assumptions to my 850-bed hospital with 49,000 catheter days per year, I can expect 2 BSIs due to CAUTI yearly. Repeating this exercise with the CUSP post-intervention CAUTI rate [2.14/1,000 catheter days] and Maki's rate of secondary BSI [0.4%], I can expect 1 BSI due to CAUTI every 2 years. Now the 2012 rate of CAUTI at my hospital was actually 2.15 (essentially the same as the post-intervention rate in the CUSP report), so I can expect 1 BSI secondary to CAUTI every 7 months to 2 years. When I think about the resources and energy that we are expending to reduce our CAUTI rate, I have to conclude that there's not much bang for the buck. Put more eloquently, the opportunity cost is high. Or perhaps more to the point: chasing CAUTI is a fool's errand.

Photo: Saltanat Ebli, Wikimedia

Welcome back CDC (and USDA, FDA, NLM etc) folks!

There are so many unsung and underpaid federal employees that work tirelessly to keep our water clean, food safe and track and prevent infectious diseases. They were all really missed when they were away. It was particularly sad to not hear the CDC talks and latest data at IDWeek; what a waste.

But they are all back (at least until early 2014) and I hope they don't have to go away anytime soon. Sometimes you don't appreciate something until it is taken away. We appreciate you! Thanks and thanks for your service.

Oh, can you get on updating the influenza map? Come on, you've had a couple hours!  ;)

Addendum: I'm thinking a humorous story or cartoon would be of the guy responsible for reading the 16 million unread emails at CDC that have piled up. I think it should be one guy and I'd like to recommend a particular person for the job. But I'm not saying who that might be.

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.

A good time to ditch contact precautions?

I get that no one likes to don gowns and gloves before seeing patients, particularly ID consultants who see a large number of patients colonized/infected with MDROs. I understand that touching is important for healing and that somehow wearing gloves impedes the healing touch. I even see why some still think that contact precautions place patients at greater risk for medical errors, even if the data supporting that contention is lacking. What I don't get is why infection prevention folks are pillorying one of the most effective methods we have in MDRO transmission prevention right when we need it the most.

My thoughts:
1) MDRO rates, particularly for Gram-negative pathogens like CRE and Acinetobacter are increasing
2) We have no antibiotics in our quiver, so prevention is our only hope for a decade+
3) Most prior room occupant studies are flawed and when proper methods are used, prior room occupants are not a risk factor - thus the environment isn't the only answer.
4) Hand hygiene compliance is only 60% - I know some are claiming 90%+ on their reports, but it's simply not true.
5) Gloves are massively effective in reducing the burden of organisms on hands and CP have now been shown to be effective in an RCT - (if you can look past the JAMA trial nihilists)

Which brings me to the table below modified from a study we completed a few years ago. You'll notice the red circle highlighting the per room entry contamination rate of healthcare workers hands with A. baumannii when hand hygiene compliance is 60%. The green circle highlights the contamination rate when gloves are worn with the 90% compliance achieved in the BUGG study (even ignoring that universal CP is associated with higher HH compliance).  You can see that when a healthcare worker enters an A. baumannii+ patient's room, 15% of the time they will leave the room with A. baumannii on their hands. If the hospital practices universal CP, it will be 3% of the time.

So, I get why people hate contact precautions, particularly ID-trained hospital epidemiologists. I just don't get the delight with which they limit their use given that CP are supported by the strongest evidence that our dismal science can muster. I suspect, again, that I won't have to live that long to witness their regret.