Thursday, July 29, 2010
The guidance summarizes 15 key scientific reports going back to 1969 and then issues FDA’s non-binding recommendations. The reports study evidence that antimicrobial use in food-producing animals develops resistant bacteria, as well as evidence that bacteria is transmitted from the animals to humans. Almost every report concludes that using antimicrobials in food-producing animals poses a public health risk due to the development of bacterial resistance (the reports that do not reach the same conclusion say simply that there wasn’t enough evidence at the time to reach any conclusion at all).
Not all antimicrobial use in livestock is problematic – FDA does make the point that using antimicrobials is beneficial when it ensures animal health. However, sometimes antimicrobials are not used to prevent, treat, or control any disease, but to increase rate of weight gain or improve feed efficiency. Further, some of these antimicrobials are medically important for use in humans. As it is critically important that we maintain the effectiveness of antimicrobials for humans, FDA now calls non-therapeutic animal use “injudicious.” FDA recommends that non-therapeutic use of antimicrobials in animals be discontinued, and that all use should be overseen by veterinarians.
The guidance notes that FDA’s suggestions are non-binding, and requests comments from all interested parties.
You can read the guidance itself here: http://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM216936.pdf
FAQ on the guidance here: http://www.fda.gov/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/ucm216939.htm
Tuesday, July 27, 2010
Read the full recommendation here: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/IndividualChanges/DailyOralCarewithChlorhexidine.htm
There’s been plenty of talk on Google Flu Trends since it launched in early 2009 in the midst of H1N1. Twitter and other Web 2.0 platforms are similarly being used to track syndromic trends to detect early outbreaks. CDC has even suggested that as retail health clinics like RediClinic and MinuteClinic, with their modern IT infrastructure and national presence, serve as early detectors of syndromic trends.
As personal health records gain in adoption, these could also provide opportunities for de-identified surveillance for targeted syndromes.
Monday, July 26, 2010
The researchers built the algorithm to look for mutations in a specific MRSA enzyme called dihydrofolate reductase (DHFR). DHFR is necessary for MRSA to replicate itself and is also a key source of drug-resistant mutation. The algorithm looks for mutations in DHFR with two key characteristics. First is a positive design mutation which is a mutation that still allows the enzyme to function. The second is a negative design mutation which is a mutation that blocks the function of the drug.
The algorithm could be incorporated into better drug design to beat MRSA's drug-resistant mutations. For example, scientists would be able to design drugs that can pre-emptively deal with possible resistance in the future.
Wednesday, July 21, 2010
Clinicians have hypothesized that bacteriotherapy works by reestablishing the normal population of microflora in a patient’s colon, but have previously been unable to test this due to limits in microbiology. Now, The New York Times has reported another successful bacteriotherapy treatment – this time with a new development.
A woman had lost 60 pounds over the course of an 8-month-long C. difficile infection, and her clinician, Dr. Khoruts, turned to bacteriotherapy as a last resort. The procedure was again successful, resolving the patient’s diarrhea within one day. However, Dr. Khoruts did something different from the other cases – he took genetic snapshots of the patient’s colonic microflora before and after the fecal transplant. He found that before the transplant, the population was severely deficient in Firmicutes and Bacteroidetes bacteria, but 14 days after the transplant, the colonic microflora was dominated by Bacteroides species strains – just like the healthy donor’s.
Dr. Khoruts’s results strongly support the idea that fecal bacteriotherapy normalizes the bacterial population in the colon, resulting in restoration of normal bowel function. Because he focused on which bacteria were present before and after transplantation, his work opens up the possibility of refining this therapy to use specific microbes grown within a controlled environment. Not only would that kind of scientific advance make the therapy more widely available, but it would eliminate the risks associated with human donor specimens.
Researchers are just beginning to understand the millions of bacterial species that live in and on humans, and their role in keeping us healthy. This field of research may present many more opportunities to develop novel therapies, and the mounting evidence of successful fecal bacteriotherapy points the way to future clinical studies.
Pediatrics article: http://www.pediatricsupersite.com/view.aspx?rid=65701
New York Times article: http://www.nytimes.com/2010/07/13/science/13micro.html
Dr. Khoruts's Journal of Clinical Gastroenterology abstract: http://journals.lww.com/jcge/Abstract/2010/05000/Changes_in_the_Composition_of_the_Human_Fecal.10.aspx
Tuesday, July 20, 2010
I also had a lively discussion with Paula Ghazarian from Via Christi Hospital-Wichita on a different aspect of the issue. One of Paula's concerns is the definition of "hand hygiene opportunity." It's catchy to say "foam in, foam out," which implies that hand hygiene should be done every time someone enters and exits a patient room. Everyone thought this approach would improve compliance, but healthcare workers who are going from room to room replenishing supplies or delivering meals are challenged to comply with it. For example, healthcare workers who are taking contaminated equipment from the patient's room to the soiled utility room (while still wearing their soiled gloves) point out that they cannot complete hand hygiene until they have dropped off the equipment. As a result, people start to make exceptions - which are logical, but which have the effect of undermining the message.
What's the hand hygiene challenge at your hospital?
Monday, July 19, 2010
SHEA published a guideline on making a business case for infection control that listed concrete steps to help IPs evaluate resource options using economic analysis, which in turn can be presented to hospital executives who are making budget decisions. Dr. Eli Perencevich, who helped write the document, talked about the core concepts at this year's APIC conference.
The idea that I like the best is calculating the additional number of bed-days that become available as a result of good infection prevention. hospitals make money by bringing in new patients. The number of patients a hospital can accomodate is limited by the number of beds available. In addition to calculating cost saved, IPs can also show the revenue generated by reducing infection rates.
Tuesday, July 13, 2010
I will write more about each of these topics in the next few days.
In the mean time, the Vecna team is having a wonderful time. Ron did a celebrity photo shoot with Dr. Peter Pronovost, the author of Safe Patients, Smart Hospitals. The Wheel of Infection at our booth was a big hit with IPs.
Monday, July 12, 2010
1. The role of an infection preventionist shouldn't be an "infection control cop". Contrasted against the Semmelweis approach of berating clinicians and providing constant reminders.
2. The people who are most careful in the operating room are often those who are the least careful outside the operating room - cited his own experience when his own patient picked up MRSA.
3. Because primary care and life expectancy is improving globally, more surgical procedures will occur, and there will be more opportunities for surgical site infections.
4. Described the checklist creation process. It is an involved process that can require up to 50 iterations before a usable checklist is developed. Goals are to create a checklist that can be executed quickly and is simple to understand. Implementing a checklist is "more than dropping a sheet of paper in the operating room."
5. Only 25% of hospitals in the US are currently using the checklist (I'm assuming he's talking about the surgery checklist). Washington state implemented it statewide and achieved reduction of infections by 25%.
NY Times Article
Finally, I am at the APIC Conference this week and so are many of my fellow bloggers. Come to booth #1107 to meet the bloggers!
Sunday, July 11, 2010
We're looking forward to Dr. Pronovost's keynote tomorrow as well as Dr. Perencevich's talk on "Economics and Clinical Consequence of your Decision Making." We've already been catching up with IPs and other attendees on our way to the trip. Looking forward to hear what's on your mind.
We'll be periodically posting during the conference, so visit the blog often over the next few days. Drop by our booth 1107 if you'd like to connect with us.
Thursday, July 8, 2010
Class I Recall of Cepheid’s Xpert MRSA/SA Blood Culture Assay products for use with GeneXpert Dx System
“On July 1, 2010, the company issued a press release and sent its customers a revised Corrective Action Notice letter instructing them not to report the MRSA negative result when a MRSA negative/SA positive result is generated on the Cepheid MRSA/SA Blood Culture Assay. Instead, customers were instructed to conduct further antimicrobial susceptibility testing to determine the MRSA result. The MRSA positive/SA positive results generated on the Cepheid MRSA/SA Blood Culture Assay can still be reported. The new instructions will be incorporated in future product labeling. “
The FDA goes on to note that Class I recalls are the most serious type of recall, and that if the products are used, there is a reasonable probability that they will cause serious adverse health consequences, or death.
More information, including model and lot numbers, can be found on the FDA’s website at: http://www.fda.gov/MedicalDevices/Safety/RecallsCorrectionsRemovals/ListofRecalls/ucm218002.htm.
Tuesday, July 6, 2010
Their theory, which the authors call the parasite-stress hypothesis, states that infectious disease adversely affects the developing brain because it diverts energy from the brain’s growth to dealing with the parasites. If the growing brain doesn’t get the nutrients and energy it needs, then it will not develop as well as a sufficiently nourished brain, which therefore leads to lower intelligence. The authors do note that parasite stress is likely not the only cause of the global variation in intelligence, but is most probably one of a number of contributing elements.
Interestingly, previous studies have shown that the frequency of asthma and allergies correlates with both higher intelligence and reduced exposure to pathogens. This leads the paper’s authors to hypothesize that the relationship between intelligence and autoimmune diseases might be dependent on exposure to infectious diseases. If a developing child is exposed to fewer infectious diseases, the brain can develop better; however, the body then doesn’t have as many infections to fight, and perhaps it turns on itself as a result.
The study certainly raises a number of issues, including the validity of IQ tests as a measure of intelligence, and issues about how to combat vicious circles (countries are poor because they are sick, and are sick because they are poor). However, setting those aside, the findings seem to underscore the importance of preventing infection to keep us both healthy and smart.
The link to the full text of the paper is here: http://rspb.royalsocietypublishing.org/content/early/2010/06/29/rspb.2010.0973.full
Monday, July 5, 2010
Wheat rust is a type of fungal infection that attacks the wheat plant's stem by forming red pustules on the plant and eventually causes the crops to die. The disease is highly infectious - responsible for killing one fifth of America's wheat harvest in the first half of the 20th century.
The discovery of a wheat rust resistant gene in the 1940s led to genetically modified wheat seeds that were resistant to the fungus and seemingly eliminated the disease for the next 40 years.
Scientists have now found that the fungus is making a comback and in a more virulent form. The first case was discovered in 1998 in Uganda. The fungus has evolved to overcome the resistant gene in the wheat plant and has become more lethal to the crop. The new variant, called Ug99, quickly spread to Kenya and Ethiopia and then to the Middle East, evolving into new forms as it spreads. Scientists fear that it will make its way to Southeast Asia and the Far East where 3/5 of world's wheat is grown.
In order to combat the fungus, scientists have developed over 60 experimental varieties of wheat with multiple resistant genes. However, whether or not any of them would work remains to be seens. An even bigger challenge is figuring out how to distribute the new seeds to all of world's wheat growing regions.