Tuesday, September 30, 2014

Antimicrobial Stewardship: The President, PCAST and Beyond

There's been a lot of excitement the past couple of weeks surrounding the release of several overlapping documents: the PCAST Report, the National Strategy for Combating Antibiotic Resistant Bacteria, and the President's "Combating Antibiotic-Resistant Bacteria" Executive Order. The Order is interesting in that the effort is to be coordinated by the National Security Council staff and guided by a task force co-chaired by the Secretaries of Defense, Agriculture and HHS. By next February 15th, The Task Force is to submit a 5-year National Action Plan and The Secretary of HHS is to establish a Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria. The additional components include improved antimicrobial stewardship, promoting novel antibiotic and diagnostic discovery, strengthening national surveillance, and finally preventing outbreaks and transmission through identifying and evaluating additional strategies in the healthcare and community settings for the effective prevention and control of antibiotic-resistant infections. Woo woo! Infection Control was mentioned!

The primary focus of the Executive Order and related reports, if you go by length and depth of recommendations, is antimicrobial stewardship. The orders include: (1) requiring hospitals (including DOD and VA) and other inpatient healthcare delivery facilities to implement robust antibiotic stewardship programs (2) monitoring stewardship through NHSN (3) encouraging USDA, FDA and EPA to continue efforts to reduce antimicrobial use in animals. I encourage you to read all three documents.

One of the best reasons to blog is that it forces you to read the literature, so when I finished reading the PCAST report, I grabbed the latest issue of JAMA. Toward the end of the issue there is a Clinical Challenge case of a 32-year-old man with recent travel to Venezuela and a skin and soft tissue infection. Without giving away the case (although the diagnosis is obvious), I wanted to highlight the fact that the proper diagnosis was missed by 10 clinicians "who collectively prescribed oral amoxicillin, cefadroxil, cephalexin, azithromycin, clindamycin, and cefdinir as well as intramuscular ceftriaxone and topical bacitracin, mupirocin, and polymyxin B." Of course, since the diagnosis was missed by all 10, none of these treatments had any effect. Thus, all of these antibiotics were unnecessary and when multiplied by the thousands of cases just like it that occur every single day, you get a sense of the scope of the antimicrobial overuse/misuse problem.

Now, this is just one random case but I think it highlights several major challenges facing antimicrobial stewardship. First, it shows that proper diagnosis requires proper training in infectious diseases and not just new diagnostics. Given that infectious diseases is specialty in decline, it is likely that proper training in the recognition of infectious syndromes will not exist in the future. No new PCR test would have helped this poor patient since none of the clinicians thought to order the existing PCR in the first place. Second, medical students, residents and fellows are not adequately trained in antimicrobial prescribing. They can't learn how to prescribe antibiotics after a few (non-standardized lectures) and without the supervision of ID physicians (since they won't exist in the near future) during their clinical rotations. It has gotten so bad for the field of infectious diseases that many antimicrobial stewardship programs are now managed by non-ID clinicians.

So here are my recommendations for what needs to be included in the next Action Plan:

1) Improved reimbursement for Infectious Disease clinical activities since the major reason residents are choosing not to do an additional 2-3 years in ID fellowship training is that the additional training actually LOWERS their salary compared to non-ID boarded hospitalists

2) Increased funding for ID training programs

3) Federal support for a 3rd year ID fellowship (after the 2-year clinical fellowship) in either Hospital Epidemiology, Antimicrobial Stewardship or both

4) Increased research funding to identify barriers to infection control and proper antibiotic prescribing and interventions to improve both

The Reports last week were an amazing step. However, it will not be enough to have antimicrobial stewardship programs without infectious diseases physicians available to guide their implementation and train the next generation of non-ID clinicians. And of course, without the proper science guiding the selection and implementation of interventions, stewardship and infection prevention programs will have limited utility. A long way to go, but exciting to finally get started.

image source: recent Field Museum (Chicago) Exhibit

Saturday, September 27, 2014

Welcome back to Iowa, Mike!

There has been so much going on lately—a tragic Ebola outbreak, the spread of EV-68, the release of the PCAST report—that we’ve simply not been able to keep up on the blogging front. We do have day jobs, after all, which brings me to the point of this post: welcoming Mike Edmond back to Iowa, where he’s now Chief Quality Officer at the University of Iowa Hospitals and Clinics. 

Mike and I trained together at Iowa two decades ago, and 5 years ago we decided to start this blog as a way to provide timely opinions about current controversies in hospital infection prevention. One of my first posts referenced a JAMA editorial penned by Eli Perencevich, and within the year Eli had settled in at Iowa and joined the blog

I guess this site has some kind of gravitational pull, because we’re now all colleagues here in Iowa City. Although Iowa City is the center of the universe, we’re aware that we need to solicit guest posts from elsewhere to prevent our blog from becoming, well, too corny. So please, if you have something you wish to get off your chest about HAI prevention, feel free to email one of us about contributing a guest post.

One advantage of hiring Mike, I should point out, is that we’re saving money on white coats—the image below is a requisition that I signed earlier today, as the ID division director at Iowa. Once I noticed what the requisition was for, I quickly cancelled it, knowing how Mike feels about the white coat….

Friday, September 26, 2014

Enterovirus 68 in 38 States

Yesterday, CDC released updated statistics that describe the emergence of EV-D68 in the US. Last month the virus appeared in Missouri and Illinois but quickly spread with 226 confirmed cases now in 38 states. Clearly these numbers underestimate the extent of EV-D68 illness since most hospitals are unable to test for this virus and once it's confirmed in a region, additional testing provides few benefits.

The NY Times reported that the University of Chicago Medicine Comer Children’s Hospital had to go on diversion three times in the last month because their emergency department was filled with children suffering from acute respiratory illnesses. Prior to this outbreak, they hadn't diverted ambulances in 10 years. It is possible that other viruses are contributing to the problem; however, CDC reports that of the specimens sent to their lab about half were EV-D68 positive and a third were positive for other enterovirus or rhinovirus strains.

The NYT article also mentioned that Children’s Hospital Colorado saw ~3,600 children in the past month with approximately 10% requiring hospitalization. Christine Nyquest, the hospital epidemiologist quoted in the article, stated that her hospital was facing a bed crunch and having difficulty maintain adequate supplies of albuterol.

Thursday, September 25, 2014

Overprotection Does Not Equal Protection: Ebola and Healthcare Worker Deaths

There is a disturbing, if not surprising, post in Bloomberg describing the horrible conditions that healthcare workers face when caring for patients with Ebola. In the current outbreak it is estimated that over 300 healthcare workers have been infected and 150 have died. It is clear that the systems designed to protect healthcare workers are failing. The central problem is that the temperatures inside the "Ebola Suits" can reach 115 degrees and can take a long time to safely remove. To begin to understand the problem, all you have to do is read this quote from Douglas Lyon:

“The first 15 minutes I was just hot...After that I was hot and had a wicked headache. Each breath in was a mix of a hint of cool relief and the feeling of suffocation. Each breath out was as warm and hot and humid as the rest of you.”

How long can you wear such a suit? How carefully will you remove such a suit? I suspect that it's hard to be deliberately slow when you're suffocating. On top of that, these suits are expensive. A facility caring for 70 patients is estimated to go through 200 sets of protective equipment per day at $77 each - $15,400. This is in countries where they can't normally afford to purchase alcohol hand rub, so hospitals distill it themselves from sugar cane or other sources.

The suffering and cost would be fine if bodysuits were both effective and necessary; however, this might not be the case. Our co-blogger Dan and colleagues wrote a wonderful opinion in the Annals last month that highlighted CDC recommendations: contact and droplet precautions - a fluid-impermeable gown, gloves, a surgical mask, and either goggles or a face shield along with shoe/leg coverings if the patient has “copious” secretions and N95 mask if they are undergoing an aerosol-generating procedure.

CDC does not recommend full-body HazMat suits.

Apart from asking you to read the paragraph below and suggesting that if we had better science around infection prevention, we'd have safer hospitals and less debate around things like HazMat suits, I would like to close with a quote from the Annals commentary: "Exceeding these recommendations may paradoxically increase risk. Introducing new and unfamiliar forms of personal protective equipment could lead to self-contamination during removal of such gear. Requiring HazMat suits and respirators will probably decrease the frequency of provider–patient contacts, inhibit providers' ability to examine patients, and curtail the use of diagnostic tests...Using extra gear inflates patients' and caregivers' anxiety levels, increases costs, and wastes valuable resources."


Usually, when I'm frustrated about the lack of science around infection prevention, I end my post by requesting adequate research funding. What is entirely obvious is that we take infection prevention for granted. We know hand hygiene should be 100% and we have gloves, gowns, masks, bodysuits, yet we fund NO research on how to improve hand hygiene compliance, develop better gloves or design new bodysuits that clinicians can remove safely. We are now paying a price for this lack of attention. I hope that federal agencies or the Gates Foundation will fund infection prevention studies that determine ways to improve systems of prevention so that caring for patients with Ebola isn't life threatening and so we no longer transmit deadly pathogens in our hospitals.

Sunday, September 21, 2014

If ever there were a saint...

Here's an interview with an amazing and brave woman, Cokie van der Velde, on the front lines of the Ebola epidemic--it's scary, sad, hopeful and humbling.

Photo:  Nichole Sobecki, BBC News

Sunday, September 14, 2014

The Ebola War

Things are just awful in Liberia, and getting worse elsewhere as well. The problem now clearly outpaces the response, resulting in shortages of everything from barrier protection to hospital beds. Worse, there is a breakdown in civil order and trust that makes it impossible to do the hard work of case identification, contact tracing and education--which is what ultimately brings epidemics under control. 

The latest, and somewhat controversial, call is for a large-scale military or quasi-military response to the outbreak. Although there are clearly downsides, experts from Peter Piot to MSF leaders to Mike Osterholm are calling for military involvement. 

The need for such involvement is based simply on the scale of this disaster—WHO, CDC, non-governmental groups like MSF, no group has anything close to the logistical capability of the military to quickly deploy personnel and supplies almost anywhere in the world. If, as MSF suggests, military assets are “not…used for quarantine, containment, or crowd control measures”, which have backfired (particularly in Liberia), such a response could help bring essential capacity where it is needed most. The chart below provides a comparison of the total budgets for the US military, CDC, WHO and MSF. I realize that the military is not designed for infectious diseases outbreak response, but we’ve invested in a massive military complex (to the exclusion of investment in many other areas, including infectious diseases prevention), so I’m not sure we have any choice: the United Nations to coordinate, UN member nations' military assets to move materials and people, and the CDC, WHO, MSF and others to provide expertise.

Saturday, September 13, 2014

Top Papers in Infection Prevention

Last week, Andreas Voss gave a talk on the year's top papers in infection prevention at ICAAC. He graciously allowed us to post his slides to the blog. To see his presentation, click here. Thanks, Andreas!