Tuesday, May 24, 2011

Using Google to Track MRSA

It’s hard to believe it’s been nearly 3 years since Google launched its Flu Trends site. Flu Trends uses Google search queries to forecast outbreaks of influenza. The simplest example is trending total queries for "flu" over time to see if there are patterns indicating an outbreak. Google’s results found strong correlation between its search-based forecasts and CDC’s actual surveillance data.

Now, a group of out of University of Chicago has used the same approach to forecast MRSA outbreaks. Google search terms for “MRSA” and “staph” were used to predict MRSA hospitalization rate. Like Flu Trends, the MRSA predictor showed strong correlation between predicted and actual outcomes. If subsequent validations hold, Google search trends could be used as a proxy for hospital-reported data to support MRSA surveillance.

Monday, May 23, 2011

Biotech fills Pharma gap


A recent article in Bloomberg Business Week says that only two of the top 6 drugmakers (as determined by market value) are developing antibiotics. As IPs and pharmacists, many of our readers are already well aware of this neglected area of development. The void in the market has created an opportunity for sufficiently innovative competitors, and biotechnology companies are getting into the business as a result.

Big pharma has been getting out of the antibiotics business because the revenue potential for antibiotics is significantly lower than for medications used to treat chronic illness. Antibiotics are used in limited courses for several weeks at a time, as opposed to medicines that are used to treat chronic conditions over long periods. Additionally, as Bloomberg Business Week notes, doctors are advised to limit use of antibiotics because of concerns that overuse can cause resistance. Both these factors have a negative effect on antibiotic sales, removing the motivation for big pharma companies to develop new antibiotics. (It's worth noting that the concern about drug resistance is a well-founded one; drug-resistant bacteria cost the US healthcare system more than $34 billion and 100,000 lives last year, according to the Infection Disease Society of America, as cited by Bloomberg Business Week.)

We’ve previously written about the shortage of new antibiotic development on this blog, particularly as relates to NDM-1, and it’s comforting to know that some companies are trying to fill the general void. Bloomberg mentions Optimer Pharmaceuticals Inc. as an example of a biotech company developing an antibiotic. Optimer’s Dificid, developed to treat Clostridium difficile infections, could potentially be approved by the FDA by the end of this month. If so, it would be the first drug approved to treat C. diff in 25 years.

Other companies mentioned in the article are Trius Therapeutics, The Medicines Co., Paratek Pharmaceuticals Inc., Cubist Pharmaceuticals Inc., and Durata Therapeutics. All are in final testing of antibiotics that would be submitted for FDA approval in the next two to three years. While it’s certainly good to develop new lines of attack for bugs that are resistant to current antibiotics, it definitely does not diminish the need for vigilance when prescribing the currently existing drugs.

Article in Bloomberg Business Week: http://www.businessweek.com/news/2011-05-17/drug-resistant-germs-lure-biotechs-to-create-new-antibiotics.html

Friday, May 13, 2011

The Tyranny of Zero Tolerance

Think about the most complicated infection control patient you have ever had. My worst patient was admitted with necrotizing fasciitis that had eroded almost the full circumference of of her trunk and spread to her perineal area. Naturally, she had an indwelling urinary catheter and several central lines. Her wounds were constantly draining and she was able to spend, at most, an hour a day out of bed. Our goal was to keep her from acquiring both a BSI and an SSI. She was with us about 2 months before she acquired each type of infection.

Zero tolerance is generally accepted as the mantra for demonstrating commitment to reducing HAIs. According to APIC zero tolerance generally means that no one on a healthcare team believes that even one HAI is acceptable. The assumption is that zero tolerance will eventually result in zero HAIs.

The zero tolerance approach represents a shift from believing HAIs as a normal risk of hospitalization. Certainly no one wants to go back to that way of thinking. But is zero tolerance realistic? Does it support the culture of blame that many quality officers are trying to eliminate?

We all know that healthcare is a complicated service compounded by the fact that peoples’ bodies break down, including their immune systems. Was it realistic to think we could prevent our patient from getting HAIs given the massive assault on her body from her first infection? Good nursing care during her admission resulted in a reduction of her initial wounds to about half of their original size. Unfortunately, the initial infection was not treatable and it spread to other sites despite aggressive care. It was at the time of that spread that the other infections occurred.

If I had strictly ascribed to the zero tolerance policy, my course of action would have been to conduct quality analyses and try to determine which staff performed poorly and/or what they had done that was wrong. That would have been followed by remedial actions including the possibility of staff discipline.

But in this case I believed that the concept of zero tolerance was not appropriate. There seemed no point in discussing the infection prevention strategies that might have been breached. The staff were familiar with prevention strategies. They were devastated when the HAIs developed. Reviewing prevention strategies or threatening punishment would have been viewed as a punishment and, I believe, a disincentive for future prevention efforts.

The question was whether, given this patient's underlying condition, any prevention strategies would have been successful? The answer was probably not. So I wondered what the teachable moment would be directed toward. I wondered if there was anything positive that could be taken from this situation. It occurred to me that, given the massiveness of the patient's initial infection, what the staff had done was to prevent HAIs for a relatively extended period of time. They had taken the necessary infection control precautions that were successful until the patient’s immune system was overwhelmed.

Is there a place for zero tolerance? Yes, but not as an inviolate goal. To hold that belief without allowing different perspectives may be detrimental to prevention efforts. Sometimes we must give ourselves credit for keeping patients infection-free for as long as possible given the forces that both patients and staff are fighting against. Supporting staff even in the face of failure can be an effective way to reinforce good practice for the many other patients whose conditions will challenge our best efforts.