Our long and winding road

We issue frequent reminders on this blog about how little we really know about healthcare-associated infection (HAI) prevention, and have called many times for increased support for HAI research. We also enjoy pointing out well-designed studies that help advance the field. So I’m happy to direct you to SHEA’s just-released update on HAI prevention advances and roadmap for HAI research. From surveillance to prevention, implementation and dissemination, this review summarizes our progress-to-date and provides an exhaustive list of research priorities. So read it and get to work!

How does a study become an internet meme?

According to the internet the steps to starting an internet meme are: (1) have an idea, (2) find a picture that reflects what you want to imply and (3) "now this is where the skill comes in."  The first two steps are pretty easy to understand, but I'm currently trying to sort out what step 3 actually means.

For an example of a study becoming a meme witness Maggie Carrel's (geography professor at Iowa) recent ICHE study where she geocoded Iowa Veterans and found that those living near a large pig CAFO where at greater risk for MRSA nasal colonization on admission to an acute care hospital. You can read a bit more about her study in Maryn McKenna's Wired blog post.  I suspect Maryn's writing is where the skill comes in because Maggie's study is now a meme (image below) from PEW's health initiative - Supermoms Against Superbugs. Super.

h/t to co-author Tara Smith for finding the meme.

Gratuitous Hand Hygiene Post: Automated Surveillance Technology

Today, May 5th, is Hand Hygiene Day. If you're looking for links to hand hygiene campaign material, the CDC page is a great place to start. Instead of the usual hand hygiene video or bundle of interventions, I wanted to highlight a recent study our group completed that was just published in AJIC.

The study was led by Melissa Ward, one of Loreen Herwaldt's star research coordinators.  Melissa, spent many months scouring the medical literature for evidence that automated hand hygiene surveillance systems are accurate, effective and cost-effective. After an initial 3,463 article abstracts were identified, she painstakingly reviewed each one to find 42 articles that were original science and evaluated at least one aspect of at least one surveillance technology.  Four types of systems were identified: electronically assisted/enhanced direct observation, video-monitored direct observation, electronic dispenser counters, or automated hand hygiene monitoring systems.

To save you some time, here are the main conclusions from the study: Few articles assessed the accuracy of these electronic monitoring systems and those that did reported "little to no hand hygiene compliance rate differences between direct observation and automated or electronically assisted systems, including electronically enhanced direct observation." However, two studies found differences favoring the automated approach, so we concluded that "more research should be done to validate the accuracy of these systems."

Most importantly there was little evidence that "these systems can improve hand hygiene compliance" and there is currently "limited evidence to recommend the adoption of one type of system or approach as no high-quality quasiexperimental studies, cluster-randomized trials or decision-analytic modeling studies have been completed or published that would allow the comparative effectiveness of system types or individual systems to be assessed."

So what is my gratuitous (second definition: "free") advice: "Facilities should pilot test systems compared to gold-standard, directly observed compliance surveillance before they are widely implemented."

WHO: Antimicrobial Resistance

Last week the WHO released a report covering global surveillance for antimicrobial resistant bacterial pathogens. The report starts off by highlighting the major gaps in knowledge about the magnitude of the MDR-bacterial problem and suggests that the post-antibiotic era is a very real threat. While the levels of resistance in the report are very alarming, the authors also note that worldwide surveillance lacks coordination, so it's likely we're only seeing the very tip of the iceberg.  One interesting aspect of Dr. Fukuda's introduction was his acknowledgment that TB, malaria and HIV have much better surveillance systems and should serve as models for MDR-bacterial surveillance.

The report focuses on "nine" bacteria-drug combinations: E coli vs 3rd gen. cephalosporins and fluoroquinolones,  K. pneumoniae vs 3rd gen. cephalosporins and carbapenems, MRSA, S. pneumoniae vs. penicillin, nontyphoidal Salmonella and Shigella vs. fluoroquinolones and N. gonorrhoea vs. 3rd gen. cephalosporins.

I think the take home point is summed up in the reports Figure 1, which I've pasted below.  No new antibiotic classes since 1987. We can safely say that the bacteria didn't take a 30-year break while we rested on the laurels of the prior generation(s).

The report is 232 pages long, so you have two options if you want to learn more: (1) Head over to the WHO website and read the whole thing or (2) Listen to my 15-minute interview on Iowa Public Radio from last week. Just click on the audio player below or head over to IPR's page and listen there.



For additional reading on the US burden of antimicrobial resistant bacteria:

1) Sievert DM et al. ICHE January 2013 (2009-2010 NHSN Summary)

2) CDC 2013 Antibiotic Resistance Threats Report

MERS: A Primer

Yesterday the CDC reported the first case of Middle East Respiratory Syndrome (MERS) in the United States. The patient is a healthcare worker who flew from Saudi Arabia to Chicago (via London), and then traveled by bus to Indiana, where he is currently hospitalized.

I suspect this is the first of many posts on this topic. In case you have not been following the MERS story, I put together a summary to get you up to speed.

Epidemiology

• Approximately 400 cases have been reported since the first case was reported in 2012.
• All cases have been acquired in 6 countries in the Arabian peninsula, though some cases became symptomatic after travel to other countries.
• The virus (a novel coronavirus) appears to have originated in bats, but antibodies to the virus have been found in camels.
• Transmission dynamics are not completely understood. Human-to-human transmission does occur, and some cases are associated with contact with camels.
• About 1 in 5 cases have been healthcare workers who cared for patients with MERS.

Clinical (excellent reference by Hui et al here)

• The incubation period is 2-13 days (median, 5 days).
• The illness is characterized by pneumonia, which in most cases is severe (80% require ventilatory support).
• Typical cases begin with fever, cough, chills, sore throat, myalgia and arthralgia, followed by dyspnea and rapid progression to pneumonia.
• Severe cases may be associated with ARDS, septic shock and multiorgan failure.
• Fever is almost always present.
• GI symptoms (nausea, vomiting, or diarrhea) are present in 1/3.
• Chest imaging is always abnormal; findings include bilateral hilar infiltrates, patchy infiltrates, segmental or lobar opacities, ground glass opacities and small pleural effusions.
• Routine laboratory abnormalities are variable.
• Mortality rate is ~30%. In fatal cases, median time from presentation to death is 11.5 days.
• Asymptomatic infection can occur.

Diagnostic Testing (detailed instructions by CDC here)

• In the US, all testing is performed by public health laboratories.
• PCR is available for BAL fluid, tracheal aspirate, pleural fluid, sputum, NP/OP swabs, NP wash/aspirate, and serum.
• Antibody testing: acute (first week of illness), convalescent (>3 weeks after acute sample obtained).

Treatment

• No specific antiviral therapy is currently available.
• Treatment is focused on supportive care.

Infection Control and Prevention (CDC guidance here)

• Contact and airborne precautions are indicated for patients under investigation, and suspected and confirmed cases (see CDC case definitions here).
• Eye protection (goggles or face shield) is specifically recommended.
• At this time, there is no available vaccine or chemoprophylaxis.

Photo: Cynthia Goldsmith/Maureen Metcalfe/Azaibi Tamin, CDC.

Urine Trouble (part 2)

I recently blogged about the teenager who urinated in the Portland water reservoir and the decision made to drain 38 million gallons of water in response. Well, the latest news is that Portland officials kind of changed their minds. Instead of draining the reservoir, they will transfer the water to an empty reservoir to be used as a water feature. I'm not entirely sure I get that logic either.

Dallas Songer, the reservoir urinator, seems to have a better understanding of water contamination and its implications than the Portland water experts. Here's what he said in a recent interview:

"Yeah, it's fucking retarded dude. Like, how they can do that? How can they be like, 'Yeah, we're gonna flush all that water.' Dude, I've seen dead birds in there. During the summer time I've see hella dead animals in there. Like dead squirrels and shit. I mean, really, dude?"

Photo:  The British Gazette

Clean Hands Save Lives - and now there's a book to prove it!

As most of you know, 5 May is the WHO World Hand Hygiene Day. This year's campaign is called "SAVE LIVES: Clean Your Hands campaign - ’No action today; no cure tomorrow – make the WHO 5 Moments for Hand Hygiene part of protecting your patients from resistant germs."

In honor of 5th of May and to further promote hand hygiene and the concept "Economy of Peace," French author Thierry Crouzet has authored a book describing the journey of Didier Pittet and WHO in promoting hand hygiene internationally. The book is available for purchase in print or epub and also for free in 6 languages (no Croatian?!). In addition, this group has created a new website/organization called CleanHandsSaveLives.org.

For hand hygiene fans, after you read the late Sherwin Nuland's story of Ignac Semmelweis, this could be next on your list.