Friday, January 30, 2015

More good news about MRSA. This time from VA.

It's not often that good news about hospital-acquired infections (HAI) is reported in the media. When was the last time you read an article congratulating a hospital for having lower CLABSI rates or good hand hygiene compliance? It's even rarer to hear good news about VA Medical Centers. While the quality of care in VA often meets or exceeds that in the private sector, it's rarely reported, since high quality runs contrary to established memes.

That's what's unique about today's 'Opinionator' article in the NYTimes. It reports greater improvement in MRSA infections in VA vs non-VA hospitals. To those of us that study HAI and resistant bacteria, this isn't that surprising. Integrated, public (national) health care systems, like VA, have built in incentives to prevent infections since they see the direct benefits of reduced costs and better outcomes - incentives that aren't well-aligned in other hospitals. However, to most folks it is probably surprising that VA was an early adopter of a bundled approach to MRSA prevention and has set the bar for the rest of the country.

Dan and I are both quoted in the article, so I encourage you to read it. However, I'd also like to highlight one section:
"The V.A.’s achievement is even more remarkable because its patients are older and sicker than patients in other hospitals. (Most patients are Vietnam-era vets. None are healthy young women giving birth, a large patient group in most hospitals.) They are twice as likely to come to the hospital already testing positive for MRSA. The greater the percentage of people who have the bacteria, the harder it is to control its spread. Because their immune systems are weaker, V.A. patients are also more likely to go from testing positive to full infection."
The fact that VA patients are older, sicker and often poorer than other hospitalized patients is frequently missed in the wider discussion about quality measures. When you have all the cards stacked against you and you still deliver high-quality and safe care, it should be recognized. Nice when it is.

Tuesday, January 27, 2015

$1.2 billion Requested for Antibiotic Resistance!

You don't tug on superman's cape
You don't spit into the wind
You don't pull the mask off the old lone ranger
And you don't mess around with Jim
Most days, controlling the spread of antibiotic-resistant bacteria in hospitals feels like fighting with one hand tied behind our backs, or spitting into the wind or...  For example, we have very little control over whether patients are colonized or infected with antibiotic resistant bacteria on admission. It's not like we can move a hospital from the high-prevalence East Coast to the low prevalence Upper Midwest. And once resistant bacteria become endemic in our region/hospitals, we have few reliable evidence-based interventions to prevent patient-to-patient transmission.

So, it's with some trepidation that I began reading the President's proposal to provide extra funds to tackle antibacterial resistance. Would there be any funds for infection prevention? When discussing past initiatives, we've remarked on how little attention is given to infection control programs and research. This time, however, things are looking better.

Here's how the $1.2 billion will be distributed under the current plan:
  • $650 million to the NIH and the Biomedical Advanced Research and Development Authority to expand development of antibacterial drugs and diagnostics
  • $280 million for CDC-led efforts to curb overprescribing of antibiotics and track outbreaks of drug-resistant infections
  • $47 million would go to FDA to evaluate new drugs and monitor livestock antibiotics use
  • $77 million to USDA to help develop alternatives to the antibiotics used in farm animals
  • $75 million to DoD and $85 million to VHA to focus on reducing antibiotic-resistent infections in health care settings 
This is a well thought-out list and is very close to how I would wish to distribute the resources. I would perhaps request a bit more for CDC to study HAI prevention interventions in addition to stewardship efforts; however, this extra-funding, while long overdue, is on target. I'm also encouraged that the President is asking for increased funds and not reducing other critical research in infectious diseases like HIV, TB and malaria. Let's just hope Congress can approve this request and it's renewed annually. It will be nice to get back to work preventing HAI - this time with two hands and a mask to keep the spit off our faces.

Monday, January 26, 2015

SHEA 2015 Update: Abstract Deadline (January 30th), Pro-Con Session and Certificates

SHEA - Orlando, May 14-17, 2015
The SHEA spring meeting in Orlando is really coming together. With the abstract deadline approaching (January 30th) and the full agenda finalized, I wanted to highlight a few things that you should know as you rush to register before the February 13th early registration deadline.

1) Register before February 13th and save $100. If you aren't already a SHEA member - become a member at least 48 hours before registering for the meeting to save even more! Hope to see you in Orlando - May 14-17, 2015.

2) This year, there are two certificate courses that you can select when registering. In addition to the annual SHEA/CDC Training Certificate Course in Healthcare Epidemiology, there is a new SHEA Certificate Course in Post-Acute and Long-Term Care Track. When you register and attend either course, you will receive a certificate in addition to CME/CE. Specific sessions for the SHEA/CDC course (purple) and LTC course (orange) are in the grid below.

3) Finally, I wanted highlight the Friday afternoon (May-15th) Pro-Con session titled "Does Pay for Performance Reduce HAI?" In this session the "Con" side saying the policy doesn't work will be discussed by Grace Lee, MD MPH. As you know, she published an important study on the topic in the NEJM (2012). In that quasi-experimental study, she showed that there were no changes in CLABSI, CAUTI or VAP rates before/after the 2008 nonpayment policy implementation in 398 NHSN hospitals. You can read my blogpost on the study here. On the "Pro" side, Teresa Waters, PhD will discuss her recent JAMA-Internal Medicine study (2015) that showed that the CMS policy was associated with reduced HAI. Using a quasi-experimental design and data from 1381 US hospitals participating in the National Database of Nursing Quality Indicators (NDNQI), she showed that the same CMS policy was associated with an 11% reduction in CLABSI and a 10% reduction in CAUTI but no change in falls or pressure ulcers. So did the policy work or not? Gotta attend SHEA 2015 to find out!

2015 Agenda - Click to enlarge

Sunday, January 25, 2015

Media False-equivalency and the Disneyland Measles Outbreak

Many of us have watched from the sidelines as the anti-vaccine and other science-denier movements have grown through the explicit and implicit support of large media corporations. Even if 99% of scientists support the safety of vaccines, a false balance gives the anti-vax view equal time. Others have written eloquently on false-equivalency in the media and how this anti-science attitude endangers public health. There is no better example of the misguided media support of anti-science than anti-vaccine torchbearer Jenny McCarthy. Since 2007, she has made numerous false claims about vaccines on Oprah, Good Morning America and other venues. One need only to read Michael Specter in the New Yorker (2013):
Jenny McCarthy, who will join “The View” in September, will be the show’s first co-host whose dangerous views on childhood vaccination may—if only indirectly—have contributed to the sickness and death of people throughout the Western world. (See jennymccarthybodycount.com.) McCarthy, who is savvy, telegenic, and pulchritudinous, is also the person most visibly associated with the deadly and authoritatively discredited anti-vaccine movement in the United States. She is not subtle: McCarthy once essentially threatened the actress Amanda Peet, who has often spoken out about the obvious benefits of childhood vaccinations, by warning Peet that she had an angry mob on her side. When people disagree with her views on television, McCarthy has been known to refute scientific data by shouting “bullshit.”
While McCarthy's 1-year stint on "The View" has now ended, she now appears annually on "Dick Clark's New Year's Rockin' Eve with Ryan Seacrest." FYI, we're considering changing the blog name to Dan Diekema's Controversies in Infection Prevention with Mike and Eli. Parsimony is so 2014.

In addition to implicit support of anti-vax folks, there are many other examples of corporate support for anti-science beliefs. For example, in November Curt Schilling (ESPN analyst and former pitcher) took to Twitter to rail against evolution. In the wild-west that is social media, ESPN baseball writer Keith Law quickly responded with a defense of evolution and science in general. As you can imagine, only one of the ESPN "discussants" was suspended - science supporter Keith Law.

So why mention these specific examples, as there is nothing surprising about ESPN backing an ex-baseball player over a writer? The irony is that The Walt Disney Corporation owns ABC (The View, Dick Clark, Good Morning America) and ESPN. And of course Disney owns Disneyland where a seven-state outbreak of measles with at least 85 cases began. While it might be true that select anti-vax folks remain "unmoved" by the latest outbreak (it's their right to decide what eliminated diseases come roaring back), this outbreak might awaken media corporations with large amusement parks to the downside of anti-vax false equivalency. It can't help the bottom line and public image of Disney that scared parents and public health officials are recommending calling off trips to the park.

One might feel a bit sorry for Disney if they hadn't played some role in setting the stage for this and other vaccine-preventable outbreaks. However, my main concern is for the many children too young to receive the vaccine or those with suppressed immune systems whose herd-immunity shield has been needlessly laid down. "It's a Small World" will never sound the same.

Tuesday, January 20, 2015

Falling out of love with chlorhexidine?

Regular readers of this blog are aware of our on-again, off-again relationship with chlorhexidine (CHG) bathing of ICU patients. I even wrote a poem about CHG, a haiku that received no critical acclaim (see the last paragraph of this post).

Now a new study from Vanderbilt, published today in JAMA, finds that daily CHG bathing “did not reduce the incidence of health care-associated infections (HAIs)”. This single-center, pragmatic, cluster-randomized, 5 ICU study included 9340 patients and pre-specified a composite endpoint of central line associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI) and Clostridium difficile infection (CDI). The per-patient analysis revealed rates of 2.86 and 2.90 HAIs/1000 patient days in the CHG and control groups, respectively. All told, 105 infections were included in the analysis (55 during the CHG period, 60 during the control period, excluding the “washout” periods). As anyone could have predicted, the vast majority of these infections were CAUTI, VAP and CDI (more on this later). A total of 8 CLABSI were captured, 4 in each arm.

What should we make of these data? Should institutions that have adopted CHG bathing abandon the practice? Should those planning to begin CHG bathing in their ICUs reconsider? My answers to these three questions: (1) meh, (2) no, and (3) no.

For several reasons, this study doesn’t move the needle much regarding CHG bathing. Set aside the fact that it is a single-center study, and that adherence to CHG bathing was not measured. More importantly, the composite endpoint they chose includes infections for which there is no convincing evidence (and very little biological plausibility) to suggest that CHG bathing should be effective (CAUTI, VAP, and CDI). To take VAP as an example, CHG oral care is included in the VAP prevention bundle (addressing the pathogenesis of VAP, which is entry of upper airway flora into the lung). If they practice VAP prevention at Vandy, which I’m sure that they do, then they already use daily CHG oral care in their ventilated patients. I'm not sure why anyone would think that adding CHG bathing would provide an additional detectable benefit for VAP prevention. And despite a single quasi-experimental study, I don’t know anyone who thinks CHG bathing is likely to have a significant impact on CDI rates. The more we learn about CDI epidemiology, the more it seems that antimicrobial stewardship interventions, rather than interventions to reduce transmission/acquisition, are the most likely to reduce CDI. As for CAUTI, well, CAUTI SCHMAUTI

The bottom line is this: the two outcomes that CHG bathing has been demonstrated to improve in controlled trials are (1) CLABSI, and (2) MRSA/VRE acquisition. This study can't claim to address either one. There were too few CLABSIs (i.e. it was way underpowered for that endpoint, given baseline CLABSI rates), and since they didn't do active surveillance during the study period they were unable to accurately measure rates of ICU acquisition of MRSA or VRE.

To sum up, CHG bathing of ICU patients should still be considered one of several adjunctive approaches to prevention of CLABSI (at least those due to common Gram-positive skin contaminants) and MRSA/VRE acquisition. What this study demonstrated, if anything, is that if your institution is practicing good HAI prevention (and has already achieved low CLABSI and MDRO rates), then adding CHG is not likely to add a measurable benefit (and that to measure any incremental benefit requires much larger studies!).

Sunday, January 18, 2015

HAI surveillance definitions update: The good, the bad, and the ugly

Here's an update on NHSN healthcare associated infection (HAI) case definitions.

First, the good:  As of January 1, CDC has modified the definition for catheter associated urinary tract infection (CAUTI). This was sorely needed to improve specificity.

The new CAUTI definition can be found here and a video on the changes can be viewed here. In summary, there are 3 major changes:
  • A positive culture requires >100,000 CFUs
  • Yeast have been eliminated from the definition
  • Urinalysis is no longer part of the definition
The new definition will better align with working clinical definitions used by physicians to diagnose and treat CAUTI.

Now, the bad:  Unfortunately, we still have the problem of CLABSI surveillance only allowing the denominator to include one central line per day even though more than one central line may be present. This punishes academic medical centers where the sickest patients receive care. A recent study in Infection Control and Hospital Epidemiology from the University of Rochester sheds some light on this issue. Investigators there performed a case control study to evaluate the risk of multiple central lines on development of CLABSI. They compared patients with 1 central line to those with more than 1. They found that even when controlling for chemotherapy, hemodialysis, use of TPN, length of stay, age, acute and chronic illness (using APACHE and Charlson indices, respectively), patients with more than 1 central line are 3.4 times more likely to develop CLABSI.

Finally, the ugly:  Although CDC developed a definition for CLAMBI (central line associated mucosal barrier injury bloodstream infection) and hospitals are using it, these infections will still be publicly reported as CLABSIs. The end result is that hospitals with large populations of oncology patients are forced to report falsely elevated CLABSI rates. Since there is agreement that CLAMBI is not preventable and actually not causally associated with central lines, this situation is both ridiculous and harmful.

Over the past several weeks, there have been numerous reports in the media regarding hospitals penalized by CMS in the HAC reduction program. Interestingly, over half of the academic medical centers found themselves in the 25% of hospitals that were financially penalized. It's not surprising given that the cards are clearly stacked against them by the NHSN surveillance methodology. As the stakes get ever higher, the need for more precision in the methodology is imperative.

Sunday, January 11, 2015

The Dallas backstory

It's not everyday that Vanity Fair features epidemiologists, but this month's issue has a long behind-the-scenes piece on the Dallas Ebola cases. It's an interesting read (free full text here).