Friday, April 29, 2016

The delusion continues

There's a new paper in Clinical Infectious Diseases on the highly anticipated survey of Internal Medicine residents to solve the enigma of why no one is going into infectious diseases. It never seemed to be a mystery to me, but having data is always helpful, providing that you interpret it correctly. And here that caveat concerns me a great deal.

The survey results were divided into three groups: those applying or intending to apply to ID fellowship, those interested in ID but deciding not to apply, and those with no interest in ID. Of those who had an interest but didn't apply (the group that we should have some hopes of capturing), the number one reason for not going into ID was SALARY. Moreover, when asked what is the most important factor to increase interest in ID, all three groups said SALARY. For those going into ID and those who considered it, the percent responding salary was two-fold higher than the next most commonly cited factor (early exposure to the field of ID).

So no surprises here. But what was both surprising and alarming to me was that the discussion in the paper and the accompanying editorial both seemed to downplay salary as a factor in the current dearth of applicants to ID. The authors wax eloquently on career choice models, pedagogical techniques, the importance of mentors, etc. Salary is addressed in half a paragraph of the eight paragraph discussion. The authors of the editorial even seem somewhat astonished that the top career choice of those who considered ID but didn't apply pursued general internal medicine, a specialty that they note "is not typically considered a high remuneration specialty." I think there's no surprise here for two reasons: (1) hospitalists make significantly more money on a per hour basis than most infectious diseases doctors, particularly in the academic setting, and (2) whatever that difference in salaries is, it's magnified by the fact that two more years of training (at least) results in a lower salary. That is, you are punished economically for additional training, which many folks find too unpalatable to move beyond.

My bet is that the paper and editorial are nicely in line with IDSA's thinking since IDSA sponsored the study. And I suspect that IDSA will continue to pretend that all is well while the dumpster fire burns away. Once we get the microbiology courses in medical schools to stop making the students memorize so much the students will come racing to ID!

Carry on then.  

Thursday, April 28, 2016

More data support a common source for the M. chimaera outbreak

As we’ve suggested here and here, the information to this point strongly suggests that the M. chimaera outbreak linked to heater-cooler units (HCUs) is a “common source” outbreak, which has major implications for outbreak response. 

Another piece of the puzzle was published today by Haller and colleagues in Eurosurveillance. Read the whole thing for details of the German outbreak investigation, but the key additional findings are in the table above—brand new HCUs, and the water source at the manufacturing facility, grew M. chimaera. The genome-sequencing results are not included in this report, but read this key paragraph from the discussion below:
"Preliminary typing results indicate that the M. chimaera isolates detected by the authorities and the isolates from the manufacturer appear to be almost identical (unpublished data). The M. chimaera-positive environmental samples at the manufacturing site prompted the manufacturer to modify the manufacturing process, which now includes ethanol disinfection and an active drying of the HCU water circuit before shipment. ……According to the information provided by the manufacturer, HCUs manufactured before mid-August 2014 may have had environmental mycobacteria presence in the unit at the time of delivery [emphasis mine]. Our investigations could not elucidate if and until when contaminated HCUs may have been delivered to customers from this manufacturer." 
It is, of course, impossible to know for how long units were shipped “pre-contaminated” from this manufacturing site to users, but this now-published information only increases the rationale for removal of these HCUs from the operating room. Both Dutch and German authorities took this step, as the authors note. The US should as well—it shouldn’t take long to determine the impact on HCU function of extending the tubing sufficiently to allow this.

Wednesday, April 27, 2016

Here we go again: Active detection and isolation, C. difficile edition

An interesting study in JAMA Internal Medicine, likely to generate a lot of discussion, addresses the use of “active detection and isolation” (ADI) for control of C. difficile disease. This quasi-experimental, single-center study employed PCR screening (tcdB detection) of all patients admitted through the emergency department (patients admitted from other locations were excluded, as were “short stay” patients), and those that were found to carry toxigenic C. difficile were admitted into a kind of “quasi-isolation”—gloves were used, but not gowns or private rooms. So all-in-all, a very pragmatic (and somewhat idiosyncratic) intervention. Healthcare-associated C. difficile disease rates declined after the intervention, which students of prior quasi-experimental studies of ADI for MRSA and VRE will find unsurprising. 

At this point, I will outsource my blog post to Jon Otter and Martin Kiernan at the Reflections IPC blog. Go on, head over there for an excellent pro-con post about this study, and vote on the question posed at the end of the post. Then come back here to read my only additional observation…..I can wait (spoiler alert: I agreed with Jon).

OK, you’re back: the only thing I have to add to Jon and Martin’s excellent post is this: we’ve been here before. Recall the persuasive quasi-experimental studies (many single-center, some multicenter) of MRSA and/or VRE ADI published over the course of a couple decades. When better designed studies were eventually performed and published (e.g. STAR*ICU, REDUCE-MRSA, MOSAR, this one by Harbarth and colleagues that doesn't have a catchy acronym)—you know, studies that included concurrent control groups (control groups are for losers!), it became evident that ADI wasn’t the key to MRSA or VRE control. I think we’re headed down that road again, this time with C. difficile. Who’s going to step up and organize the multicenter, cluster-randomized trial we need to do now? Or perhaps better to ask: who is going to pay for it?

Tuesday, April 26, 2016

Peace, Love and Hand Hygiene

Sanjay Saint, Professor of Medicine at the University of Michigan and Chief of Medicine at the Ann Arbor VA Medical Center, discusses changing healthcare's culture through conformity, social learning (monkey see, monkey do) and mindfulness in a new TEDx talk. Worth a listen.


Wednesday, April 20, 2016

Efficacy versus effectiveness

Take a moment to check out this video from today's NY Times.

If a hand hygiene method demonstrates marginally better reduction in bacterial counts on hands, but is also more complicated and takes longer to complete, should it become the standard?

Related question: does the difference in log10 bacterial counts between 2.58 CFU/ml and 2.88 CFU/ml translate into a greater risk for pathogen transmission in healthcare settings?

I’ll let you ponder the above questions, as I don’t have the answers. One thing I do know: when a hand hygiene paper in Infection Control and Hospital Epidemiology is being covered by the NY Times, we’re winning!

I’ll let Eli and Mike comment on how many of the people depicted in the video are bare below the elbows!

Tuesday, April 19, 2016

Public Reporting - Do we need big brother?

I was fortunate to be an invited speaker at the 2016 ECCMID meeting in Amsterdam last week. My topic was "Monitoring Process of Care: Do We Need Big Brother?" I used the opportunity to take a big picture view of public reporting of HAI and MDRO data in the US and Europe and a closer look at the selection of process versus outcomes measures for reporting. I've posted my slides below and you can also listen to my talk on ECCMID's website. As I believe Dan stated earlier, I hope that all meetings evolve to allow free/open access to presentations like ECCMID has.

Sunday, April 17, 2016

Not just another guideline

Why is this man laughing? Because he co-authored an awesome antibiotic stewardship guideline!
The updated antibiotic stewardship guideline has been released, and is available at the Clinical Infectious Diseases website, and in pocket card and mobile versions. While the guideline will undoubtedly be essential for those tasked with establishing and running stewardship programs, it isn’t going to be frequently referenced by prescribers. 

Instead, treatment guidelines for specific clinical syndromes are more likely to guide prescribing decisions, either by direct application or via their incorporation into facility specific practice guidelines or CMS measures. Thus the impact of the stewardship guideline will be limited unless stewardship principles are also incorporated into treatment guidelines, pathways, and quality measures. This point was made in a recent editorial by Brad Spellberg, Arjun Srinivasan and Chip Chambers, and I know that HICPAC plans to summarize the stewardship principles that should be incorporated into all ID-related treatment guidelines. 

Ensuring that antibiotic stewardship principles are considered carefully when infection-related quality measures are established is a continuing challenge—once a measure is tied to payment and/or public reporting, the law of unintended consequences takes over, including consequences for antibiotic use. We learned this with the ill-fated “4-hour rule” for treatment of community acquired pneumonia, which likely led to an untold number of inappropriate antibiotic doses and C. difficile cases, and we’re struggling with it again around the new sepsis measure

Finally, truly informed stewardship awaits a lot of research and development progress: to better establish dose and duration of therapy for common conditions, to improve diagnostics to allow more rapid directed therapy, as well as improved capacity to distinguish bacterial, fungal and viral etiologies, to more precisely determine the relative impact of different antibiotics on host microbiota (and the implications thereof), etc., etc., etc. Someday, I hope, we’ll be able to look back at the 2016 guideline and marvel at how rudimentary it is—for now, though, it’s excellent, so go read it!

Photo credit: US News and World Report