When the US opioid epidemic causes a Serratia outbreak

We are in the midst of an almost unprecedented opioid epidemic in the U.S.  Last year (2016), overdoses caused 64,000 deaths, which was a 22% increase from the previous year, while fentanyl-associated deaths increased by 540% over the past three years. (I wanted to add a thousand exclamation points after the 540, but thought better of it)

Fifteen years ago, Belinda Ostrowsky reported a 26-patient outbreak of S. marcescens bacteremia in a surgical ICU that was ultimately linked to contamination of fentanyl by a respiratory therapist who had diverted the narcotic for their own use. (The CDC has a nice webpage describing 30-years of HAIs associated with drug diversion by healthcare workers)

Given the current opioid epidemic, we should expect an increase in hospital outbreaks associated with narcotic diversion. So, it is not surprising to read about a five-patient cluster of S. marcescens bacteremia linked to narcotic diversion by a PACU nurse just described in ICHE by Nasia Safdar and colleagues at University of Wisconsin. Even before the Serratia cluster was identified, a nurse found hydromorphone and morphine PCA syringes with the tamper-evident caps no longer intact and drug levels undetectable in a locked automated medication dispensing cabinet. The subsequent investigation eventually found 42 syringes had been tampered with and narcotics replaced with saline or lactate ringers before the nurse was fired. Unfortunately, even though the outbreak was clonal, the tampered syringes were destroyed before they could be cultured. However, four patients were epi-linked to the PACU nurse and the fifth patient was the nurse's father. (I resisted adding an exclamation point here too)

There you have it, but if you want to read beyond the ICHE report, there is an interview of Dr. Safdar over at STAT. We certainly don't need more things to worry about with the current opioid epidemic, but we should all make sure we keep talking with our pharmacy colleagues about narcotic thefts and keeping our theft policies and prevention practices up to date.

Donation

What a terrible couple of weeks. Hurricanes Harvey and Irma, not to mention a huge earthquake in Mexico, pummeled North America. If possible, one of the things that we can do in these situations is donate to recovery efforts. Here are a couple suggestions for places where you can donate:

UNICEF has sent teams to Chiapas and Oaxaca and has expanded their fundraising efforts to cover those affected by the hurricanes and earthquakes. Donate please

The five living past Presidents have started the One America Appeal, which initially responded to Harvey but has been expanded to assist with Florida's recovery. Donate please

Finally - and we have been hesitant to even mention this -  many SHEA members have completed races to raise funds for antimicrobial stewardship scholarships through the SHEA Education & Research Foundation's "Race Against Resistance." Runners have included fellow bloggers Tom and Scott. Not to be outdone, the University of Iowa has put together a team 5k run on September 30th.  We hope you can contribute to this important educational and prevention effort. Donate please

Thank you

Are "One-Offs" Becoming Routine

one–off

play

adjective \ˌwən-ˈȯf\

After eight years investigating hospital outbreaks, and about 15 years trying to make the best possible use of surveillance data while at CDC, I still struggle with the tensions inherent in mixing surveillance and performance measurement. The past decade has been a roller-coaster of thrills and perhaps some spills in terms of attention, resources, refinement, and usefulness of HAI surveillance led by CDC; yes, you could probably blame me for several aspects of NHSN reporting you may find unsatisfying (take your pick – perhaps I will expand another day). However, I having recently retired from CDC and am transitioning to Emory Healthcare and Emory University. Although It has been almost eight months. It has been a fascinating transition. The learning curve is steep, and not just for re-entering clinical medicine (that is another story), but also navigating the pathway which integrates the business of healthcare delivery, quality of healthcare delivery, and research opportunities. Slightly easier was learning how to navigate the Emory Parking situation (took 3 months). Much easier was recognizing that the performance quality metrics linked to HAI prevention are getting a lot of attention and a lot of action. It only took a few sessions listening to the quality improvement teams reporting on their target HAIs to understand two things. First, the C suite leaders really care. I had assumed this while at CDC, but it was illuminating to see up close how hard these teams worked to influence HAI prevention. Second, it was becoming somewhat routine to report out on “exceptions to the rules” of HAI reporting. There are many names for those scenarios when an HAI is justifiably reported, but either considered not preventable with evidence based prevention practices or not clinically the infectious event represented by the HAI. While at CDC we routinely heard about these: CLABSIs that “shouldn’t really be counted”, MRSA BSIs that really “weren’t ours”, CAUTIs that really don’t represent an infection. Now these reported HAIs were being called “one-offs.”

The NYT reports the term ”one-off” comes from earlier industrial beginnings with the quantity of items produced in manufacturing process, such as taking one-off, two-off, or twelve-off the line to sample or give-away. However nowadays it can refer to any exception of the rule – such as a recent one-off boxing match that really should not ever have happened. 

In an HAI paradigm where we aim for 0 infections, one-offs may either be unavoidable (not preventable) or wrongly attributed to the device, location, procedure. I have historically known of these in terms of byproduct of using proxy measures. I had previously published an editorial on the value of proxy measures of infection as a tool for quality improvement (Meaningful measure of performance: A foundation built on valid, reproducible findings from surveillance of health care-associated infections).

In that editorial, we outlined necessary steps to reduce the inaccuracies inherent in using such an approach. Now that progress has been made in HAI prevention since 2010/2012, many of these HAI events that conspicuously remain and continue to plague our patients, often don’t fit neatly into the intent of the surveillance definitions. Left with these “one-offs,” it is often difficult to know what to do more to prevent them. Surgical patients with fistulas and central lines that don’t have an infection related to insertion or maintenance processes, neutropenic patients that don’t quite meet the definition of MBI-BSI, I have even heard of tissue transplantation related bacteremia categorized as CLABSI. No doubt, changes have occurred since 2011 to improve CAUTI reporting, and neutropenia-related bacteremia. However, the pace is slow. The one-offs are starting to pile up. Perhaps improved risk adjustment of HAI data will mitigate the influence of the one-offs on healthcare facility performance measures. Until then, kudos to the quality folks and infection control teams making prevention progress. However, I hope we can reward them soon with improved performance measures. Perhaps there are surveillance lessons that can be learned from these one-offs after all. 

If you are interested in sharing one-off stories I have started a registry here - maybe we can fill in some gaps and accelerate the process of changes in surveillance methods.

And what about antimicrobial scrubs?

Ascot: a neckband with wide pointed wings, traditionally made of pale grey patterned silk

The role that environmental transmission plays in the spread of important pathogens is increasingly recognized. One of the major mechanisms by which pathogens are thought to spread is via contaminated healthcare worker clothing. A major reason that gowns are included in contact precaution is that they are felt to interrupt the transmission from patient/environment to HCW attire. An old (2010) study that Dan Morgan completed found that gowns became contaminated 11% of the time when caring for patients with MDR-Acinetobacter and 5% of the time when caring for patients with MDR-Pseudomonas. A repeat (2012) study found that gowns became contaminated during 4% of HCW visits caring of MRSA+ patients, 5% for VRE, 2% for MDR-Pseudomonas and 13% for MDR-Aceintobacter.

With so much contamination and a desire to rid the world of unnecessary gown use, investigators have been exploring the benefits of antimicrobial textiles, such as scrubs. If these novel scrubs could reduce contamination, maybe we could drop the dreaded gown and go with universal gloves for contact precautions?

Which brings us to a ASCOT study by Deverick Anderson and colleagues funded by the CDC Prevention Epicenters Program. ASCOT: Antimicrobial Scrub Contamination and Transmission. The investigators examined the benefits of two different antimicrobial scrubs (Scrub 1: silver-alloy and Scrub 2: organosilane-based quaternary ammonium and a hydrophobic fluoroacrylate copolymer emulsion) vs standard poly-cotton surgical scrubs in a 3-arm RCT during 3-consecutive 12-hour ICU nursing shifts. The primary outcome was change in total contamination on the nurses scrubs as sum of CFUs. Of note, all MDRO colonized patients in the study were placed on contact precautions and HCW placed gowns over their scrubs and wore gloves while caring for those patients.

The study collected many cultures: 2919 from the environment and 2185 from the HCW clothing. 41 nurses were randomized but one was excluded for a total of 40 nurses caring for 102 patients during 167 encounters. Their primary finding was the scrub type had no effect on HCW clothing contamination (p=0.70) There is a lot to unpack in this study and it warrants a careful read - a lot of data! but I've included Table 3 below with the contamination before/after each shift. Overall, the median CFU increase was 61.5 (interquartile range [IQR], −3.0 to 191.0) in the control arm, 73.0 (IQR, −107.0 to 194.0) in the Scrub 1 arm, and 54.5 (IQR, −60.0 to 215.0) in the Scrub 2 arm.

There were acquisition events during 39 (33%) of the shifts with 20 (17%) environmental acquisitions and 19 (16%) acquisitions on HCW attire. Looking at the 19 HCW attire acquisition events, 12 (63%) were confirmed: 7 from the patient, 3 from environmental contamination, and 2 from the patient/environment.

Overall, the authors reported that there were no benefits from either antimicrobial scrub. However, there was significant transmission from patient or environment to HCW attire.  Back to the drawing board on antimicrobial scrubs?  Maybe. I would like to see the study repeated in a hospital where contact precautions are not used to see if benefits might exist in settings where gowns are not worn when caring for MDRO+ patients. With this much acquisition of nurses' clothing, it's going to be hard to ditch gowns, unfortunately.

Oh, and I love the ASCOT name. Brilliant.

The cartoon editorial, microbiology edition: An idea whose time has come!

I was excited to read the editorial in this month’s Journal of Clinical Microbiology (JCM), by Alex McAdam (JCM Editor in Chief), entitled “Prevalence and Predictive Values”. You can read it here too, because I’ve pasted it below:

Brilliant—a simple concept (diagnostics 101!) explained in a simple format. And as an associate editor of JCM, I can attest that this concept is frequently missed by submitting authors, not to mention practicing clinicians and hospital epidemiologists. 

This issue is also foundational to diagnostic stewardship, as it emphasizes the importance of limiting diagnostic testing to patients who have a reasonable pre-test likelihood of disease (pre-test likelihood being the individual-patient equivalent of population prevalence). 

It also explains why we’ll never “get to zero” for healthcare-associated infections (HAIs), even if all HAIs were preventable. Take the example of hospital-onset C. difficile infection (HO-CDI). The more successful your prevention program is at reducing whatever the “true” incidence of HO-CDI is, the lower will be the population prevalence—and the lower the positive predictive value (PPV) for the very sensitive CDI tests we now use. Positive tests will still occur, no doubt, and will be counted toward the HO-CDI rate—but they’ll be increasingly likely to be clinical false positives. 

Now I need to go start working on a good cartoon editorial about whether CAUTI exists….

Summer Quick Hits (with the Award for the Most Eyebrow-Raising Article Title of the Year)

Trying to recover from summer vacation (Alaska = thumbs up, especially during a summer heat wave) and gear up for a new school (and blogging) year, so here are a few quick hits from recent articles:

Two articles highlight several HAIs that aren't often included in surveillance and prevention efforts:

• Len Mermel has a nice systematic review in CID examining the burden of bloodstream infection related to short-term peripheral venous catheters (a.k.a. peripheral IVs - not midline or PICCs).  Used in a substantial number of hospitalized patients (esp. as we're better about central line necessity), these devices have a much lower risk of BSI when compared to central venous catheters (2-64 fold higher risk for CVCs); however, given the vast number of devices used (Len estimates ~200 million adult patients in the U.S. annually), the number of BSI events are likely high. A number of interesting details are in the paper, so worth checking out. 
• A nice commentary out of the UK in Lancet Respiratory Medicine advocates for an increased focus on healthcare-associated pneumonia, particularly that which occurs outside of the ICU (and is not ventilator-associated). 

Both of these papers highlight HAIs that are not in the "Big 5" (CLABSI, CAUTI, SSI, MDROs/C. diff, and VAE) but cause patient harm.  Broadening an IP surveillance and prevention program to include these events does have some challenges, however.  The worry about objective surveillance definitions that came to a head with VAP certainly applies to HAP, and the volume of patients at risk for a PIV-related BSI invites the need for an automated system for surveillance.  Nonetheless, with reductions in the Big 5 (well, except VAE as I'm still not sure how to tackle that one), it's perhaps time we look to expand our scope.

Finally, a paper that wins the award for the most eyebrow-raising title of the year: "Hematophagous Ectoparasites of Cliff Swallows Invade a Hospital and Feed on Humans."  Try reading that without saying "What?? Gross."  The authors outline their nosocomial "outbreak" of two ectoparasites related to a massive swallow roost on the outside of a community hospital.  One inpatient noted a rash illness, and testing of ticks and bugs identified the presence of human blood in 17% of the captured critters.  Hospital invasion!  Feeding on humans! Talk about a riveting agenda for your next infection prevention committee meeting!

Diagnostic Stewardship

The following is a guest post from Dr. Dan Morgan, GFOTB (Good Friend Of The Blog):

This week Preeti Malani, Dan Diekema and I wrote a viewpoint in JAMA discussing diagnostic stewardship, or “modifying the process of ordering, performing, and reporting diagnostic tests to improve the treatment of infections and other conditions.” In other words, guiding laboratory ordering to prevent contradictory results and reporting results in a fashion that makes treatment more appropriate. There really are two Criteria for Diagnostic Stewardship modifying laboratory testing:

1) Does it modify the process of ordering, performing and reporting tests? 

2) Does it improve the appropriateness of patient management? 

When I discussed diagnostic stewardship with my non-medical wife, she asked “you mean they don’t do that? Why would they do tests that contradict other results or provide second or third line antibiotic choices?” 

This is why I think diagnostic stewardship has so much potential. It is about making laboratory ordering more rational, which is hard to debate. Although medicine has existed with the idea that doctors knew best how to order and interpret results, we are now seeing they often don’t, as predicted by psychologists Danny Kahneman and Amos Tversky in the 1970s; “Intuitive judgments are liable to similar fallacies in more intricate and less transparent problems.” 

Doctors ordering and interpreting test results are like other people, often irrational. Diagnostic stewardship makes testing more logical to improve patient care. Ultimately this process shouldn’t be limited to urine cultures, blood cultures and C. difficile testing but applied to new molecular detection panels and non-ID tests, like cascading tests for anemia or limiting PSA testing in young and elderly men. And there has been interest in this idea from areas outside of ID. 

The fact that diagnostic stewardship reduces false-positive tests that contribute to publicly reported HAIs means there is likely a lot of incentive to support these processes. But we shouldn’t forget there are important patient benefits too, including avoiding unnecessary antibiotics, avoiding the distraction of misdiagnosis, and improving the ability of HAI rates to truly measure care.