India restricts antibiotic use in light of NDM-1

The Indian Union Health Ministry announced this week that it is planning to tighten control of antibiotic use. Certain antibiotics, such as carbapenem, imipenem, and meropenem, will be put under more stringent restrictions if the new rule is passed. Other ideas under consideration are mandatory “drug control” and “infection control” committees in hospitals, where the drug control committee will oversee the use of controlled antibiotics and the infection control committee will monitor and analyze infection rates.

The proposed changes are aimed to combat the spread of NDM-1 superbug and to slow the evolution of other drug resistance bugs in the future. NDM-1 superbugs are resistant to most antibiotics; in fact, the prevalent use of antibiotics in India partially contributed to the emergence of the superbug. NDM-1 first appeared in India in August of this year and has quickly spread to other countries, including the U.S. (See our previous blog post).

Link to Article

Drug resistant Klebsiella a growing problem for the Chicago area

Chicago has seen an alarming rise of infections caused by Klebsiella pneumoniae Carbapenemase (KPC) bacteria.  KPC is a multi-drug resistant bacterium that was first identified in Chicago in 2007.  Earlier this year, 37 health facilities in Chicago reported an average of 10 KPC cases each, up from an average of 4 cases in 2009 at 26 facilities.  75% of the cases are from nursing homes and long-term care facilities.

The challenge for Chicago hospitals and nursing homes now is to contain the spread of KPC bacteria.  Early identification of patients who may be carriers is key, as well as better communication between different facilities when a patient colonized with KPC bacteria is transferred from one to another.

Links to relevant articles:
IDSA article on KPC cases in metropolitan areas
Chicago Tribune article on KPC cases in the Chicago area

"In trying so hard to contain the infection, had we lost sight of the person?"

Dr. Pauline Chen asks this question in her article, "Losing Touch with the Patient," which was published in last week's New York Time (October 21, 2010).  The story Dr. Chen tells is one of the patients for which she helped care, a man with an infection from a multi-drug resistant organism and who spent the last few weeks of his life in contact isolation.  Dr. Chen observed the patient's emotional shift during contact isolation - as healthcare workers' visits became infrequent and less interactive due to isolation precautions, the patient withdrew emotionally. 

Contact isolation is meant to prevent the spread of infections.  Previous researches have shown that patients in contact isolation receive lower quality of care and are more dissatisfied with their care.  The question, therefore, is how hospitals can best balance the interest of individual patients to the patient population at large.

Links to contact isolation research:
Safety of Patients Isolated for Infection Control

Ethical Implications of Active Surveillance Cultures and Contact Precautions for Controlling Multidrug Resistant Organisms in the Hospital Setting

Arizona uses video competition to educate public about infection prevention

In the spirit of International Infection Prevention Week (last week), the Arizona Department of Public Health launched a video contest to educate the public about infection prevention.

According to one news source, The East Valley Tribune, hospital-acquired infections kill 2,000 people in Arizona each year, which is higher than the number of people killed in car accidents.  Arizona is currently not considering public reporting of HAIs and is instead focusing on basic preventative measures such as hand hygiene and central line insertion practices.

Interview with iScrub Lite developer Chris Hlady

iScrub Lite, a free iPhone/iPad app for recording hand hygiene observations, is making a lot of buzz in the infection prevention community since its launch over a year ago. I recently chatted with one of the app’s developers, Chris Hlady, to learn the story behind iScrub Lite.

EP: Could you describe what iScrub Lite does?

CH: iScrub Lite is an iPhone/iPad app for hand hygiene observers to record their observations. Hand hygiene observers are often infection preventionists, they measure hand hygiene compliance by watching healthcare workers (HCWs) go in and out of patient rooms and see if the HCWs are properly washing their hands both before entering and after leaving a patient’s room.

EP: Where did the idea for iScrub come from?

CH: It’s been over 2 years since the original conception, so I may not recall all the details. Basically when Apple first announced the App Store, I felt that it was going to become a very important platform. I began working on a game for the iPhone in order to learn how the platform worked. My advisor, Dr. Phil Polgreen, who is an epidemiologist at the University of Iowa, was very interested in hand hygiene and he gave me the idea for an app for hand hygiene.

We demoed a prototype at the local Iowa APIC conference in 2009 and got positive feedback from the nurses there. That experience encouraged us to move forward with the concept.

EP: What were some key considerations in the design process?

CH: We wanted the app to be simple and very easy to use. We saw that many hospitals were using paper forms to record their observations, and their processes sometimes required multiple forms.

We wanted to create a standard that improves the existing process.

Another goal for iScrub Lite was to cut down the feedback period. We found that in many cases observations were not communicated until weeks or even months later. We wanted to create a tool that lets nurses get results sooner and enables faster communication to HCWs.

EP: How many iScrub users are there?

CH: 3,000 users have downloaded iScrub Lite in the last 6 months.

EP: What kind of feedback have you been getting?

CH: We have been getting a lot of feedback. A lot of people are asking for iScrub Lite for the Blackberry and Android. We also get a lot of inquiries for iScrub Pro.

EP: What’s going to be in the Pro version?

CH: In the Pro version our main goal is to make it easier for nurses to make observations on a large scale. We also want to make reporting easier so that it will enable benchmarking. For example, a hospital can benchmark compliance among units in the same hospital or against other hospitals.

EP: What was the most surprising thing you learned during the making of iScrub Lite?

CH: How many different ways hospitals are doing hand hygiene observation. There are a lot of inconsistencies and disagreements over hand hygiene policies and practices.

Chris Hlady is a graduate student in the Department of Computer Science at the University of Iowa. Fellow graduate students and CompEpi research group members Donald Curtis and Jason Fries are also developers on the iScrub team.

Big pharma make big bets on infectious diseases: J&J and Glaxo invest in treatments for infectious diseases

Infectious diseases are catching the attention of big pharmaceutical companies lately. Over five years ago, GlaxoSmithKline started investing in flu vaccines with the anticipation that new variants of flu viruses are emerging and will cause global pandemics. Glaxo began delivering its new H1N1 vaccine last week and has already received over 440 million orders from governments around the globe.

Another pharmaceutical giant, Johnson & Johnson (J&J), recently acquired Crucell, a Dutch vaccine producer, for $2.42 billion. The acquisition is a strategic move that positions J&J in the vaccine market. J&J also announced that it plans to expand its research to encompass infectious diseases like HIV and hepatitis C.

Vaccines are more difficult to make and require larger upfront investment than prescription drugs. So, as patents for brand-name drugs expire and margins fall, big pharma companies are looking to produce vaccines to bolster a business that is less likely to be undercut by low-cost producers.

Variations in CLABSI surveillance

At a recent client meeting, an infection preventionist asked how to ensure consistency in infection reporting among hospitals, considering infection rates will soon be published on CDC's Hospital Compare website. I am not sure anyone has an answer to her question, but given the recent study results published on CLABSI surveillance, there exist large variations in how hospitals measure and report CLABSI rates. The study suggests that a lot of work remains to be done to ensure consistency and validity in how hospitals conduct CLABSI surveillance.

Here are some of the findings from the study, which was published in the October issue of the American Journal for Infection Control (AJIC):

• 100% of the infection control departments reported inclusion or exclusion of central line types inconsistent with the CDC CA-BSI definition
• 50% calculated line-days inconsistently
• Only 50% used a strict, written policy for classifying BSIs
• Though more than 80% of the hospitals surveyed reported having a formal, written policy about obtaining blood cultures, less than 80% of these address obtaining samples from patients with central venous lines, and any such policies are reportedly followed less than half of the time
• Substantial variation exists in blood culturing practices, such as temperature thresholds, preemptive antipyretics, and blood sampling (volume, number, sites, frequency).

Finally, hospitals expressed much greater confidence in the validity of CA-BSI as an internal/historical benchmark than as an external/peer benchmark, and the factor most commonly believed to contribute to CA-BSI occurrences was patient risk factors, not central line maintenance or insertion practices.

This Week is Infection Prevention Week!

This week is the International Infection Prevention Week and this year's theme is "Infection prevention is everyone's business." The Association of Infection Prevention (APIC) is sponsoring a number of webinars on infection prevention starting today.

Link to APIC's list of events for this week is here

Magic Number 7

Here is a question for you: For how many days were you asked to take your last antibiotic prescription? Was it 7 days? If so, have you thought of why?

Sunday's New York Times (October 17th) featured an insightful as well as worrisome opinion piece on why antibiotics are almost always prescribed for 7 days, as opposed to any other number. It turns out that there is really no scientific basis for the number 7. It's simply a convention and a habit. In fact, the author of the article points to a research study that shows that in the case of uncomplicated pneumonia, taking antibiotics for 3 days is as effective as the recommended 7 days.

The author then smartly points out that by having people take more pills than necessary, the overdose not only contributes to rising healthcare costs, but also to the evolution of antibiotic-resistant superbugs.

Here is my simple calculation:
If 3 days of antibiotics is as effective as 7 days, then a person will be taking 4 more pills than necessary (assuming he/she is taking one pill per day). That's more than double the necessary dosage. Translate this to the entire U.S. population, this means that at any given time, there are twice as many antibiotics taken than necessary!

New York Times article here

Research study on the effectiveness of antibiotic treatment here

Germ fighting superheros roam New York City streets

The Association of Professionals for Infection Control (APIC) teamed up with Alliance for Consumer Education (ACE) to launch a new hand hygiene education using two superheros. Ace Clean and Iron Man demonstrated proper hand washing techniques in New York City's Times Square on October 1st.

Video link for the superheros is here

Long journey for electronic medical record adoption

The Sunday's edition of The New York Times (10/3/2010) has a story on the journey of Doerr Brother's healthcare software company. The story exemplifies the challenges facing many technology companies that service the American healthcare industry.

John and Tom Doerr started ClearPractice in 1999, a software company that made electronic health record products for small physician practices. The brothers thought that the obvious benefits of EHRs would make their software an easy sell. However, 10 years into the business, they had fewer than 500 doctors using the product. Since 2000, many large health systems have adopted EHRs but adoption among small physician practices is still lagging.

Small physician practices provide more than 85% of the healthcare services offered in the U.S. Almost all physicians operate on a fee-for-service model, which means the incentive is to do more of everything - tests, prescriptions, surgeries, etc. - but no incentive to adopt EHRs. The federal stimulus package will reduce the cost for adopting EHRs through subsidies; however, a fundamental shift in healthcare economics is needed in order to drive the adoption of EHRs among small physician practices.

Hospitals have historically viewed infection prevention as a heavy expense. The same rationale that prevents small physician practices from adopting EHRs, i.e. high investment cost and lack of quantifiable benefits, also prevents hospitals from adopting best practices and new technologies for infection prevention. Mandatory reporting and pay-for-performance are pressuring hospitals to scrutinize their infection rates more closely, which will hopefully drive up adoption of new technologies and best practices

Times' article on Doerr Brothers

Interview with creator of the board game Pandemic

Pandemic is a board game in which players cooperate to control outbreaks and eradicate disease. It’s played almost on a weekly basis at Vecna by a multi-disciplinary team of employees including software engineers, clinicians, systems administrators, project managers, and attorneys. It’s a unique game in that no single person wins; the team either wins together or loses together.

Board Game Geek: Pandemic Page

I had a chance to interview Pandemic’s creator Matthew Leacock this past Wednesday. Matthew formerly worked as a UI specialist for Yahoo and is now part of a new venture called Sococo. He designs board games on his spare time. He generously gave his time to answer a few questions:

R: What was your inspiration for Pandemic?

M: Classic board games like Monopoly are notorious for allowing an individual player to dominate the entire game while everybody else watches as they get screwed over. “Euro-games” or German board games are shorter and keep players involved and engaged. If you’re eliminated, you don’t have to wait too long to play again. If it’s not your turn, you’re still engaged with the game.

Co-op games like Lord of the Rings really broke it out for me. It wasn’t a kids’ board game where outcomes were randomly determined. Lord of the Rings also introduced the notion of self-sacrifice where you could perform an action that benefitted the team but didn’t necessarily help you out.

R: How did you decide on the theme for Pandemic?

M: The choice of subject matter was a natural fit. In Lord of the Rings, the villain is Sauron who feels un-human and has an emergent behavior like a disease. When you design a game with that kind of opponent, you have to create a paper algorithm that describes how the opponent emerges, how it spreads, and its impact on the players. For Pandemic, I had to define the mechanics of the outbreaks. I also designed a game in my youth about chain reactions from a nuclear reactor with similar mechanics. Disease just naturally fit after that, and it didn’t hurt that SARS was in the news during that time.

R: How much did you rely on historic pandemics or movies about them?

M: I never saw Outbreak. I’m sure 12 Monkeys played into it a little bit. I still remember the scene where the bioterrorist is running through the security gate. I’m familiar with Andromeda Strain but that’s a bit of a stretch. Really, it was mostly because SARS was in the news.

R: What kind of subject matter expertise did you rely upon when designing the game?

M: I’ve done games in two different ways – starting with a theme and then defining the mechanics, or defining the mechanics first and crafting the theme later. It’s better to focus on the mechanics first. Put it together and make it feel right. I did play it with people who were knowledgeable about the subject matter to make sure I didn’t incorporate some huge gaffe. I considered an educational component where facts could be illustrated on cards – information about different diseases, and tips on prevention. I decided against it because it’d be too much information and too many cards.

R: Have you gotten feedback from epidemiologists or other people in public health?

M: I’ve gotten positive feedback from the CDC in Atlanta. They actually sell Pandemic in their gift store. Some epidemiologists, friends of friends mostly, have enjoyed the game. I’ll occasionally see blog posts on Boardgamegeek about somebody who’s in the industry who really enjoys the game.

R: The cooperation in Pandemic is noble. I feel real world cooperation isn’t so pure. In the SARS outbreak, for example, while WHO did a great job facilitating information sharing among researchers, many groups withheld information in the hopes of publishing before others did. Have you considered modeling that element?

M: There are a couple of cards in the Brink expansion that represent that kind of negative behavior. It was easier to design the game in the beginning when it was just the players against the disease. Having different incentives for the different roles just introduced too much complexity.

R: I know this game is making its rounds in the hi-tech community. Start-up founders and software company execs get together to play. Do you have hopes that this will be the next Settlers of Catan?

M: All of my hopes have been exceeded. It’s been translated into 12 languages and has sold over 100,000 copies. I’d be happy if people pointed to it and said that it’s a very fun, collaborative game.