Study finds correlation between electronic surveillance systems and IP satisfaction

A survey study published in this month's American Journal of Infection Control looked at the impact of electronic surveillance systems (ESS) on infection preventionists' (IPs) jobs. IPs from over 200 hospitals in California participated in the survey. One very interesting finding from the study is that IPs with ESS have more organizational support and that organizational support is highly correlated with IPs' satisfaction level.

The study also provides an informative look at the changing role of today's IPs. The table below summarizes how today's IPs spend their time:

The chart below summarizes where IPs are spending their time:

Although the study finds that IPs with ESS don't necessarily spend less time on surveillance, they do allow the IPs to spend less time on data collection and more time on decision making and implementing preventative interventions.

Abstract and link to full text here

Predicting Epidemics using Social Network Analysis

We posted a few months ago on the book Connected and how social network analysis is relevant to the fields of epidemiology and infection control. In the journal PLoS One, the authors Christakis and Fowler published specifics on the study briefly mentioned in Connected about a social network experiment performed on the campus of Harvard University.

Long story short, by mapping out the network of friends in a group of over 300 students, they were able to predict the onset of a flu epidemic two weeks earlier than through random sampling or by other means. In the case of SARS or swine flu, those two weeks could be the difference between a local epidemic and a global pandemic if public health officials had access to this data. There are many potential applications for social network analysis in the study of disease, but real-time public health applications may require private health data that individuals are as yet unwilling to make available outside of a controlled study on a college campus.

Big Think: A Better Way to Predict Epidemics
http://bigthink.com/ideas/24058

PLoS ONE: Social Network Sensors for Early Detection of Contagious Outbreaks
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012948

Big Think: Nicholas Christakis Interview
http://bigthink.com/nicholaschristakis

New York State releases HAI report

Earlier this month, the New York State Department of Health released its 3rd annual report on hospital-acquired infections (HAIs). Some good news from the report:

1. Surgical site infection (SSI) rate in New York was 5.3 per 100 procedures, lower than the national average of 5.6 per 100 procedures and has been declining since 2007, when New York first started reporting HAIs.

2. Central line associated blood stream infection (CLABSI) rate has fallen 18% in the last two years.

3. The dollar savings associated with reduction in CLABSI rates in adults, pediatrics, and neonatal ICUs in New York was estimated to be between ~$2.5M and $10M.

One of the report's recommendations was that hospitals need to integrate health information technology systems to enhance infection prevention and reporting efforts.

Full Report Here

Using EMR data to determine origin of HAI

It's known that certain settings like healthcare, long-term care, and prison facilities increase the risk for certain infections. A prime example is MRSA. The challenge has been to determine where the patient acquired the infection, either from the community at large or from a healthcare facility. The distinction between the two is important for the monitoring, treatment, and prevention of infections.

A study by JS Wilson developed a process that identifies healthcare facilitiese from patients' addresses in the EMR database, automatically categorizes the address as either a healthcare facility or a residential address, and finally decides whether or not the infection is likely to be community or healthcare acquired.

This is an interesting attempt to use EMR data in assessing infection risk and opens the door to further investigating the effects of social networking on infections.

Full research paper here

Book Review: Best Care Anywhere

Philip Longman’s second edition of Best Care Anywhere is a valuable, high level summary of the history of the Department of Veterans Affairs, the story of the VistA EHR system, and how incentives can be aligned within this huge health care system to achieve some of the highest scores on quality metrics, including HAI rates.

Of particular interest to me was the story of how the VistA EHR system was originally created. VistA was the brainchild of a community of computer-savvy VA physicians, and was developed in occasional opposition to the wishes of senior leadership. A virtual “Underground Railroad” emerged to enable the continued development of the system through the 1970’s and 1980’s. VistA has become legitimate during that time, with support from several presidential administrations, and adoption beyond the VA. It's interesting that earlier this week, an RFI has been released seeking assistance in maintaining the open source nature of VistA to continue this legacy.

Longman proposes a controversial strategy of extending the VA’s model of health care delivery beyond the VA, asserting that such an approach would improve care quality and reduce health care costs. He proposes not only extending VA's reach by opening access to non-veteran beneficiaries, but also implementations of VistA well beyond the VA into community and rural hospitals.

I'm very curious to see the response of policy makers, providers, and patients towards this controversial new strategy of health care quality transformation.

NDM-1 found in Massachusetts

Back in August, NDM-1 bacteria made national news when it was discovered in Europe and many predicted that it will spread to the rest of the world. Yesterday, I read on Boston Globe's online portal that a case of NDM-1 had been found in Massachusetts General Hospital (MGH).

NDM-1 is a gene that makes bacteria highly resistant to many classes of antibiotics. The bacteria originated in India, where unregulated use of antibiotics is common. The MGH patient had recently traveled to India, had spent time in a hospital there, and was undergoing cancer treatment at MGH when the bug was discovered. Two other cases have also been identified in California and in Illinois.

The most worrisome aspect of this bug is the lack of antibiotics to treat it. Currently, only two antibiotics are some what effective against NDM-1 bacteria: colistin and tigecycline, and doctors don't foresee any new antibiotics being developed in the near future. To quote the author of the article, "The paucity of drugs reflects not only the strength of the superbug but also the long-neglected development of new antibiotics."

Full text of the Boston Globe article

Twenty-First Century Plague: The Story of SARS

During a recent visit to Toronto hospitals, I learned firsthand how the SARS outbreak affected infection prevention departments specifically and health care workers in general. I decided to do some background research on the outbreak and picked up Thomas Abraham’s Twenty-First Century Plague: The Story of SARS. It’s a quick read at 176 pages and takes the reader from SARS’ origins in southern China, tracking the disease step-by-step as it emerges in major cities, spreads internationally, and is eventually thwarted by the efforts of the global health community led by the World Health Organization. Some highlights include: the unusual transmission of SARS via bathroom drains and apartment building plumbing, how health care workers risked and lost their lives to control infections, and how network-enabled collaboration helped spread successful prevention strategies just in time.

It’s a must read for anybody curious about this recent global outbreak, and it serves as a harrowing reminder of how chaotic, confusing, and destructive a modern pandemic can be.

What's better for your health, "long ties" or "dense cluster?

Lately, there has been a lot of buzz on using social networks to change
health behavior.  Ron blogged earlier about Nicholas Christakis' book
Connected, this week a new research study came of out of MIT that shows that when it
comes to changing health behavior, having fewer friends that one knows
really well is better than having many friends whom one doesn't know well.

Professor Damon Centola from the MIT Sloan School of Management tracked
the number of people who registered for a health forum from two distinct
social networks.  In one social network, participants had "long ties" with
each other, meaning each participant knew many different people but didn't
know them well.  In the other social network, participants formed "dense
clusters," meaning each of them knew fewer people but knew them very well.

The study result showed 54% of the people from the dense clusters network
registered for the health forum and 38% from long ties network did.  This
study suggests that policies may be more effective when aimed at
communities and groups that act as clustered networks.

More about Professor Centola's study

Benefits and harms of patient isolation

There was a great essay written by Dr. Abigail Zugar on the topic of patient isolation in the New York Times.

Full text

HAI related provisions in the new health care reform bill

There has been a lot of buzz (and confusion) about the 1,000-page long health care reform bill that was signed into law in March by President Obama. Over the weekend, I challenged myself to read the entire bill and after failing to make it past the Table of Contents, I decided to read only the parts relevant to the prevention of HAIs.

The bill has several provisions on the public reporting of HAIs. Below is a summary:

• Beginning in October 2012, non rural-acute care hospitals that meet or exceed federal performance standards for at least five measures, including certain HAIs, will receive higher Medicare payments [HR 3590, Title III, Subtitle A, Sec 3001, p. 235]
• Beginning in October 2012, hospitals with high readmission rates for patients, including readmissions due to HAIs, will have their Medicare payment reduced [HR3590, Title III, Subtitle A, Sec 3205, p.290]
• Beginning in 2014, the federal government will reduce Medicare payments by 1% for those hospitals in the top quartile for hospital-acquired conditions, including certain HAIs [HR 3590, Title III, Subtitle A, Sec 3008, p.258]
• Beginning in 2014, the U.S. Health and Human Services Department will report, on its Hospital Compare website, each hospital’s record for medical errors and infections involving Medicare patients [HR 3590, Title III, Subtitle A, Sec 3008, p.258]

On a side note, there is a funny YouTube video on health care executives’ response to the bill.

Full text of bill

Not all patients with VRE need to be isolated

Findings recently published in Clinical Infectious Diseases indicate that not all strains of VRE require contact isolation, which might be seen as counterintuitive.  However, Sutter et al. looked at records for a 9-year period from a bone marrow transplant unit where contact isolation was not required for patients with VRE of genotype vanC – only for vanA and vanB. 

All patients in the bone marrow transplant unit had routine rectal VRE screening and genotyping.  Sutter et al’s goal was to estimate the risk of blood stream infections (BSIs) in patients colonized with VRE vanC.  During the years from January 2008 to July 2008, only one case of BSI was detected, while 290 isolates of VRE vanC were obtained from 273 patients.  This means that only 0.4% of the patients who had VREvanC developed a BSI, despite there being no contact isolation precautions in place.

Sutter et al. conclude that the study provides strong evidence that carriers of VRE vanC do not require contact isolation.  If there isn’t a high prevalence of VRE vanC in your hospital, this might not be as useful, but if genotyping is done and vanC is detected, the hospital does not need to spend resources on contact isolation, and patient care is improved. 

Article here: http://www.journals.uchicago.edu/doi/abs/10.1086/655824

New Technologies

We’re seeing all sorts of advances in fighting MRSA lately! AdvanSource Biomaterials Corporation recently received a patent for antimicrobial polyurethane resins, which can be used structurally or as coatings in different kinds of catheters, and are intended to help combat methicilin-resistant staphylococcus aureus (MRSA) infections.

Press release here: http://phx.corporate-ir.net/phoenix.zhtml?c=68271&p=irol-newsArticle&ID=1463328

Also, on the heels of the emergence of the NDM-1 gene, BioScience Laboratories announced that they’ve obtained seven clinical isolates of Carbapenem-Resistant (CR) Klebsiella pneumonia and Escherichia coli. BioScience Laboratories intends to use these isolates to test products for their predicted efficacy against bacteria containing the NDM-1 gene.

Press release here: http://www.24-7pressrelease.com/press-release-rss/bioscience-laboratories-announces-testing-capabilities-for-ndm1-165887.php

Octagam lots recalled

Market withdrawal of select Octagam 5% liquid preparation lots was initiated on August 20, due to an increased number of reported thromboembolic events, some of which were serious. Octagam is used to treat primary immunodeficiency diseases. The FDA advises customes not to administer any product from the lots being withdrawn.

See which lots were withdrawn, and read the full recall here: http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/Recalls/ucm223897.htm

New Hampshire releases first report on infections

Last week, New Hampshire released its first report on hospital-associated infection (HAI) rates. The report showed 134 infections during 2009, better than the 180 that was expected by state officials and lower compared to national data. Of the total 134 HAIs that were reported, 110 were surgical site infections (SSIs) and 24 were central line-associated bloodstream infections (CLABSIs).

New Hampshire passed the law in 2006 to publicly report hospital infection rates. In January 2009, all acute care hospitals began reporting CLABSIs and SSIs to the New Hampshire Department of Health and Human Services (DHHS). New Hampshire is one of 27 states that requires public reporting of hospital infections and is one of 20 states that have produced reports.

Full report here

New coating kills MRSA on contact

Researchers have developed a way to coat surfaces with an enzyme that kills MRSA within 20 minutes of contact, says a recent publication in ACS Nano.  The enzyme, lysostaphin, degrades cell walls of Staphylococcus aureus and epidermidis, thus killing the harmful bacteria. 

The researchers had spent several years studying carbon nanotube-enzyme pairs, called conjugates.  Enzymes in coating alone either degrade or leach into the surroundings, but when paired with carbon nanotubes, the authors found that the enzymes were more stable and more densely packed when embedded into polymers such as paint. 

Lysostaphin is extremely selective, killing just S. aureus and epidermidis, is harmless to humans, and does not induce bacterial resistance.  The enzyme-nanotube conjugate also doesn’t become clogged over time, a common problem with other antimicrobial coatings.  Perhaps most impressively, antimicrobial films made with the conjugate were greater than 99% effective in killing all MRSA that came in contact with the film, measured after 2 hours.  And there’s even more: the films are reusable and washable, and stable under dry storage conditions for at least a month.

The lysostaphin-nanotube conjugate could be embedded into paint used in hospital rooms, or into films to put on various other hospital surfaces.  It will be extremely exciting to see how this technology is put to use.

Link to ACS Nano abstract: http://pubs.acs.org/doi/full/10.1021/nn100932t

HAI Reporting Survey

As you’re probably aware, the Centers for Medicare and Medicaid Services (CMS) recently released a rule that details HAI reporting requirements for Medicare-participating hospitals; starting January 1, 2011, hospitals will be required to report CLABSIs to NHSN, and they will be required to report SSIs starting January 2, 2012. 

We would like to ask our readers where they are in the process of meeting the CMS HAI reporting requirement.  We’ve developed a survey, and we would really appreciate it if you could take a few minutes of your time to complete it.  It’s just 10 easy, multiple choice questions.   We’ll publish the results once they’re compiled.

Please click here to take our survey!

You didn't really want that data, did you?

Missouri, one of the first states to pass legislation requiring hospitals to reveal annual HAI rates, has possibly  deleted all their infection rate data collected from 2005-2008.  State officials say that the data is too costly to maintain, and mention the sensitivity of the data as another motivating factor. 

However, the law doesn’t explicitly give authority to the state health department to delete the infection data, or the associated tables and results produced from data analysis.  The statute says “The data collected or published shall be available to the department”.  Subsequent requests for the data by the St. Louis Post-Dispatch got conflicting answers; one state official said the data was deleted, another said that the data was available, just “not handy.”

The department later said it would take public requests for information, but they would only be honored if a programmer was available and only if the requester was willing to pay the retrieval costs.  The state data manager, Mark Van Tuinen, cited budgetary constraints as the reason for data deletion, saying “Given our skimpy resources, we’re pretty much doing what the law tells us to do” – keep data compiled for a period of 12 months. 

A note on the state health website says “Due to the sensitive nature of the data and limited resources, DHSS staff cannot provide data or records beyond what are displayed on this website.”  Van Tuinen added, “Hospitals are sensitive about comparisons with each other.”

While it’s impossible to track the changes in infection rates without the data, it is interesting to note that the 2004 law establishing these reporting requirements did not allocate any funds with which to accomplish them. Missouri apparently had to face the question of how to keep the data accessible without any money to do it.  Fortunately for the public, the St. Louis Area Business Health Coalition backed up the data each year before it was removed, so even if Missouri did delete the data, it does still exist.

Regardless of whether the data was actually deleted or not, the issue certainly raises questions about how states should frame and implement the laws that require them to report and store HAI data, and how to best serve the public while doing so.

St. Louis Post-Dispatch story: http://www.stltoday.com/business/article_9959b4e1-2634-5722-b21d-c32876d205a0.html

DHSS website with reporting note: http://www.dhss.mo.gov/HAI/definition.html

What's in a name?

Recent reports of a superbug from India named ‘New Delhi Metallo-beta-lactamase 1’ or NDM-1 are generating criticism from Indian leadership. Director General of Health Services R. K. Srivastava takes issue with naming the bug after the region and for its jab at antibiotics policy.

Srivastava "strongly refuted the naming of the enzyme as New Delhi metallo-beta-lactamase and also refuted that hospitals in India are not safe for treatment including medical tourism."

Medical tourism is growing in nations like India and Pakistan, and concern around a superbug specifically associated with the area could put the entire industry at risk. The UK Department of Health responded to the Lancet journal article by issuing an alert about the New Delhi superbug.

Controversy in naming diseases and organisms is not a new phenomenon; the World Health Organization (WHO) proceeded with caution in naming the SARS virus.

David Heymann of the WHO’s SARS team said, “We did not want to stigmatize particular areas, it could not be called Hong Kong Flu or Hanoi flu.” The WHO finally decided on the acronym SARS, which stands for “Severe Acute Respiratory Syndrome,” not realizing that “SARS” was similar to the common acronym SAR which is used to describe Hong Kong as the “Special Administrative Region.”

The problem also affects animals; naming diseases after animal species (e.g. bird flu, swine flu) can result in stigmatizing livestock, and result in their mass slaughter.

So, we’re left with letters and numbers. MBL-1, anyone?

Western eating habits: worse than you think?

A study recently published in Proceedings of the National Academy of Sciences indicates that a rural diet might protect children from inflammation and noninfectious colonic disease.  Researchers compared the fecal microflora of 14 children ages 1-6 from a rural village in Burkina Faso to that of 15 similarly-aged children in Italy.  The children from the village in Burkina Faso, Boulpon, consumed a traditional diet that is low in fat and animal protein, and high in starch and fiber, whereas the Italian children consumed a typically Western diet high in sugar, fat, animal protein, and starch, and low in fiber. 

The two populations of children's gut microflora were similar while children were still being breast-fed; the differences grew once they started consuming the local diet.  Di Filippo et al. found that the children from Boulpon had roughly twice as many Bacteroidetes species as the Italian children, and that the Italian children had roughly twice as many Firmicutes species as the children from Boulpon.  A high ratio of Firmicutes to Bacteroidetes has been associated with obesity, potentially indicating that the Western diet of the Italian children predisposes them to future obesity. 

The children from Boulpon also had a greater richness and biodiversity of gut microflora, including exclusive possession of a number of species that produce high quantities of short-chain fatty acids (SCFAs), which are known to protect against gut inflammation.  As expected, the levels of SCFAs themselves in the Burkina Fasoian children were significantly higher than those in the Italian children.  Additionally, though the Italian children were healthy, they had a significantly higher level of Enterobacteriaceae that are potentially pathogenic, like Shigella and Escherichia. 

The results indicate that a Western diet could allow potentially harmful bacteria to gain a foothold in the gut, and could predispose children to obesity and gut inflammation.

Link to the article’s full text: http://www.pnas.org/content/early/2010/07/14/1005963107.full.pdf

APIC and CDC to Provide Guidance on New CMS HAI Data-Reporting Mandate

The big news on July 30th, 2010 was that the Centers for Medicare and Medicaid services (CMS) enacted a rule requiring all Medicare participating hospitals to report data on central line associated bloodstream infections (CLABSIs) and surgical site infections (SSIs). Hospitals not submitting data on CLABSIs and SSIs may experience reduction in reimbursement payments.

APIC has taken the lead on providing information and guidance on the new reporting mandates with a webinar (details, link, and schedule still pending) in mid-August with speakers from CDC and CMS to discuss the reporting requirements. Additionally, both CMS and CDC are updating documents, support, and training.

HHS has also announced that its Hospital Compare web site will begin publicly reporting on infection rates among participating hospitals. Consumer Reports has similar data now, but Hospital Compare data can be expected to be more prevalent and current following the CMS rule and the 3,500 enrollments into the CDC’s NHSN program by Medicare participating hospitals.

Resources and information on CMS HAI Data-Reporting Rule:

CDC: New to NHSN? Page

APIC Statement on New CMS Rule

CDC Blog Posts on the CMS Rule

Text of CMS Rule

MRSA infections down, but new threat on the horizon

A study just published in The Journal of the American Medical Association (JAMA) shows that the incidence of hospital-onset methicillin-resistant staphylococcus aureus (MRSA) infection decreased by 28% from 2005 to 2008.  The measurements, taken from 9 major metropolitan areas across the country, also show that MRSA rates for healthcare-associated community-onset infections decreased 17% over the same time period. 

The study’s authors, Kallen et al., are unable to say why the rates decreased, but mention a couple possible factors.  The first possibility is the widespread implementation of MRSA prevention practices.  Kallen et al. note that “the fact that the observed reductions were greater among hospital-onset infections than healthcare–associated community-onset infections suggests that prevention practices in acute care settings contributed” to the decrease in MRSA infection rates.  Another potential factor is a change in the strains associated with MRSA infections, but the authors state that there weren’t changes in MRSA strain composition during that time period, so this is unlikely to be a valid explanation. 

Immediately on the heels of this good news comes a study published in The Lancet Infectious Diseases today, which details how a new bacterial gene might cause worldwide health problems.

NDM-1, which stands for New Dheli metallo-β-lactamase 1, makes bacteria highly resistant to many classes of antibiotics, including the carbapenems.  Unfortunately, the gene has been determined to be readily transmitted and also highly adaptable.  As bacteria that contains NDM-1 encounters bacteria that doesn’t, NDM-1 could insinuate itself into the new bacteria, thus creating a larger resistant population.  The problem is particularly worrying because there is not a single antibiotic in the discovery and production process that is effective against NDM-1-containing bacteria – and because NDM-1 is highly adaptable, it could potentially change itself to resist any drugs that are developed. 

In addition to this already grim news, most of the isolates taken from India were from community-acquired infections, which implies that bacteria with the NDM-1 gene are already pervasive.  The NDM-1 gene has also already spread to the UK and Sweden – and some of the UK patients had recently traveled to India for medical treatments. 

We’re left with a good news/bad news scenario: just as we are starting to see MRSA infection rates fall, we learn that NDM-1-containing bacteria is expected to spread around the globe.

JAMA article: http://jama.ama-assn.org/cgi/content/full/304/6/641
Lancet article: http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2810%2970143-2/fulltext

New Products

Yesterday, RyMed announced that it has received FDA approval for its newest IV connector, InVision-Plus® CS™ with Chlorhexidine-Silver Ion Engineering.  The new needleless connector has a septum that is impregnated with both chlorhexidine and silver ions, as well as a silver-impregnated fluid pathway.  Another new feature is a clear housing that lets clinicians see inside the connector. 

RyMed’s press release: http://www.rymedtech.com/assets/files/press/CS%20release%20FDA%20clearance%20--FINAL%20WEB.pdf

Censis Technologies, Inc. recently introduced their ScopeTrac system, which is an electronic tracking and management solution for endoscope reprocessing.  Inappropriate endoscope reprocessing can be a risk factor for HAIs, and ScopeTrac’s web-based system guides technicians through the required reprocessing procedures.  ScopeTrac also uses RFID and scanning technology to help manage and track the endoscopes.

Product page: http://www.censis.net/scopetrac

BMDI International has updated their line of helmet-based, daily-use respirators with the new MAXAIR 710 DLC.  This new product is a light-weight helmet with the air unit completely integrated so there are no hoses to restrict movement.  DLC stands for disposable lens cuff – easier on/off than traditional mask respirators, with no need for fit testing.  The product includes peripheral vision LEDs that give real-time safe airflow and battery information.

Product line page: http://maxairbmdi.com/01_Pages/systems.htm

Should hospitals adopt universal MRSA screening?

The legislators in Nevada are considering making universal MRSA (Methicillin-resistant Staphylococcus aureus) screening a law according to a recent news article.

MRSA is one of the most serious infections hospitals face today and its prevention has been a focus for hospitals and the CDC. The Veterans Affairs (VA) adopted a MRSA screening strategy that seemed the most aggressive: screen every patient who comes in the hospital. The cost-effectiveness of universal screening is under a lot of debate. Some argue that there is limited evidence to support the effectiveness of universal screening and that the cost as well as effort of screening every patient is too high to justify its adoption.

The VA has demonstrated a lot of success in its MRSA prevention program, and universal screening a key component. The state of Nevada is taking notice and wants the rest of the hospitals to follow suit.

P.S. Dr. Eli Perencevich posted on this topic in his blog. Check out his take on all this here.

VRE colonization test approved by FDA

Potentially good news for IPs – Spectra ™ VRE, reportedly the first chromogenic media for the 24-hour detection of VRE colonization, was approved by the FDA a week ago. According to Thermo Fisher Scientific, Spectra ™ VRE can differentiate between vancomycin-resistant E. faecalis and E. faecium within 24 hours, with no required confirmatory testing. Spectra ™ VRE is used with rectal swabs and stool specimens.

Spectra ™ VRE is manufactured, distributed, and sold by Remel, a product brand of Thermo Fisher Scientific.

Product page here: http://www.remel.com/HAI/VRE.aspx

Preventing Disease Outbreak in Pakistan Floods

A massive flood on Monday caused by monsoon rains has killed an estimated 1,500 people in Pakistan. The Pakistani government has launched a rescue campaign to save the 15,000 families in the region in need of emergency aid. As the relief efforts ramp up, officials fear that up to 100,000 people have already been hit by cholera and gastroenteritis in the affected Swat Valley.

Having returned recently from the New Orleans APIC show and with friends supporting the re-building effort, Hurricane Katrina is still fresh in memory. To compare the scale of these two disasters, Katrina similarly resulted in about 1,400 deaths in 2005. Even considering criticism of federal response, the triage and infection control effort was relatively fast. Within 5 days, nearly 5,000 people were triaged in New Orleans. Only 5 people died due to E. coli in the drinking water. Among evacuees, targeted surveillance identified 1,169 of the 6,500 in Houston’s Reliant Park medical clinic who reported acute gastroenteritis symptoms. Rehydration, isolation, and distribution of hand sanitizers controlled the outbreak. It continued for a week, but no deaths were reported due to gastroenteritis at Reliant Park.

Please consider giving to charitable organizations addressing the health needs of Pakistani flood victims. Let’s keep this from becoming an even worse disaster than it already is.

Officials fear disease outbreak in flood-hit Pakistan

Jaroka Tele-healthcare blog is following relief efforts on the ground

UNICEF Donations

IP Stories

One of my goals is to learn more about the work that infection preventionists (IPs) do on a daily basis, the challenges they face, and how they overcome them. "Interview an IP" is a project that we recently launched to let IPs share their stories with us and with each other. I am very grateful to Lisa Pope for taking the time to participate in our "Interview an IP" project. Below is her story.

Name: Lisa Pope, RN, BSN (Graduating with MSN in December 2010)

Number of years of infection prevention experience: 3 years

Which department does infection prevention come under at your hospital? Total Quality Management

1. How did you become interested in infection control?

As an RN I was looking to grow professionally in nursing but continue to have a positive effect on patient care. As I complete my Masters Degree I find myself increasingly interested in the way in which the hospital operates on a daily basis and how day-to-day operations impact the quality of care, treatments, and services a patient receives. I actually began as the Joint Commission Coordinator and was asked to take on the responsibility of Infection Prevention a few months later when the position was vacated. I can’t say I ever considered this department before but I am happy to be in the role I am in today and having the opportunity to have such a large impact on patient stays.

2. Tell us a little bit about your hospital and your work

We are a 25 bed acute care hospital located in Michigan that has adopted the Planetree approach to care giving. A model of patient-centered care in a healing environment, staff is committed to improving medical care from the patient’s perspective, empowering patients and families through education, information and encouraging healing partnerships with caregivers. The hospital offers a newly renovated emergency department with private treatment rooms, an expanded medical imaging department, a regional cancer treatment center and an Eden Care award winning 54-bed Skilled Nursing facility. The hospital has been recognized for its quality care by the Michigan Quality Improvement Organization and has earned the Governor’s Award of Excellence for Improving Care in the Hospital Setting for 4 consecutive years, the Total Benchmark Solution quality award for 2005, and the 2006 and 2007 VHA Leadership Award for clinical excellence.

In my roles, I am responsible for the daily survey preparation coordination for our Joint Commission deemed status, all infection prevention activities, including surveillance, staff and patient education programs, process improvement, IP committee chair, and quality improvement activities for our facility with professional organizations such as MPRO, MHA, and Keystone. I am also responsible for the Employee Health department which involves surveillance of needle stick injury and exposures, new hire/volunteer/intern pre-employment health screening, communicable disease reporting and policy/procedure improvement efforts.

3. What are the top three infection prevention challenges at your hospital?

The top three infection prevention challenges in our facility are reaching all staff members with IP education that is tailored to their specific department needs, accountability for compliance with issues such as Infection Prevention strategies, and compliance with newly updated procedures for issues such as needle stick injury. Change is always difficult and when you bring a multitude of changes in a close time frame it is difficult for everyone to adhere to. Just keeping the most up to date information in front of their faces is often very difficult; even in a small facility.

4. How do you engage leadership to help achieve identified outcomes? Please provide a recent initiative, highlights, and lessons learned

Engaging leadership in a small facility is often very difficult as we all wear multiple hats so we have multiple tasks in front of us each day. Getting a leader who is pulled in multiple directions to focus on “your” tasks takes a lot of one-on-one dedication. You need to be skilled in knowing how to facilitate a lot of what you are asking them to help you with. I find that bringing as much research evidence to the meeting, or providing it ahead of time, helps move the meeting along and gives them an opportunity to come prepared with questions and following up with them is crucial.

Two years ago I began giving hand hygiene education in our local schools as a project for my master’s degree class. While there I discovered that the school had taken money away from their budget that had previously gone to soaps and sanitizers for the classrooms. That left the students and teachers to provide it. This is a low income area so that could be next to impossible for most families. I returned to work to begin discussing with them our opportunity to practice our mission “To improve the health of the communities we serve” and suggested we provide hand sanitizer stations in each classroom and common area. This would be a large financial undertaking but I managed to get EcoLab to donate the sanitizer stations and their staff’s time if we purchased the sanitizer. That provided a significant savings. After having open discussions with Senior Leaders about the benefits of not only teaching hand hygiene to the young but providing them with the necessary tools, they were quick to approve the initiative. Since that time the initiative has come to include a free influenza vaccine clinic that allows access to vaccination to those who may not otherwise be able to afford it. We have seen a great decrease in the number of flu-like symptom illnesses in our local schools. This year we are reaching or to two more local schools to begin to cover our coverage area.

5. How have patient safety initiatives and state reporting impacted you and your facility?

We are very conscientious of best practice initiatives and strive to set the standard for other facilities such as ours so patient safety reporting has not had a huge impact on our facility. Our quality department has some of the finest employees who dedicate a lot of time and attention to our patient’s safety.

6. If you could impact infection control at a national level, what would you do?

If I could impact Infection Prevention at a national level I could easily see myself working in some capacity on Capitol Hill pitching process improvements that would change the way all facilities practice. I believe that every Infection Preventionist should have a standard of practice that should not be deviated from but should be modified to meet the specific need of the community it serves. Hand hygiene best practice should never be a topic of conversation just because one manager or department head thinks it is too tedious of a practice for their staff. It is what is best for our patients and we should never question that…especially if the experts are providing us with the evidence to back it up.

Antimicrobial use in livestock can hurt humans

All IPs know that bacterial resistance to antimicrobials is increasing, but the problem isn’t just poor stewardship in humans – animal use is a culprit, too. The FDA recently released a draft guidance titled “The Judicious Use of Medically Important Antimicrobial Drugs in Food-Producing Animals,” which is intended to develop policy on animal antimicrobial use as it affects bacterial resistance and human health.

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

Daily oral chlorhexidine to help prevent VAP

The Institute for Healthcare Improvement (IHI) recently recommended that adult critical care patients be treated daily with oral chlorhexidine. IHI cites a 2007 meta-study which found that treatment of mechanically-ventilated adults with oral chlorhexidine was associated with a lower risk of ventilator-associated pneumonia (VAP). After continued review of the literature, and after using chlorhexidine in the IHI Ventilator Bundle in Scotland for over a year, the IHI recommends a 0.12% chlorhexidine solution. The recommendation states that “There is little if any evidence of other oral care processes having an effect on the development of VAP, but it makes sense that good oral hygiene and the use of antiseptic oral decontamination reduces the bacteria on the oral mucosa and the potential for bacterial colonization in the respiratory tract.”

Read the full recommendation here: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/IndividualChanges/DailyOralCarewithChlorhexidine.htm

New Approaches for Syndromic Surveillance

The interest in syndromic surveillance in Ontario hospitals is understandably high given their experience with SARS in early 2003. The adoption of syndromic surveillance in hospital settings worldwide has been gradual, with mostly public health agencies and defense agencies taking an interest in this surveillance method. Since syndromic surveillance is dependent on early patient contact, and care delivery models are drastically changing, new opportunities for syndromic surveillance emerge.

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.

Playing chess with MRSA

Researchers from Duke University Medical Center developed a protein design algorithm that is capable of predicting potential drug resistance mutations in MRSA. The algorithm turns predicting mutations into a game of chess where the computer is like a chess player that tries to anticipate an opponent's moves.

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.

More on this topic

Transplanting what?

For some patients with persistent, recurring colonic infections, doctors have turned to fecal bacteriotherapy – transplanting a stool sample from a healthy donor into the patient’s colon.  Pediatrics recently reported the successful use of this technique to cure a 2-year-old girl suffering from a many-months-long infection of Clostridium difficile, using her father as the donor.  After the transplant, the girl’s symptoms resolved within 36 hours.

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

Conversations on hand hygiene

I had the opportunity to speak with a number of IPs at APIC. One of the topics that routinely came up was hand hygiene. During the poster session, I spoke with Brenda Grant from Stamford Hospital, who was presenting on the hand hygiene initiative at her hospital. By using a multi-faceted approach that included patient and health worker education and independent monitors, Stamford was able to achieve a higher hand hygiene compliance rate than when compliance was enforced by infection control staff alone. However, a challenge she and many other IPs face is to correlate compliance to reduction in HAIs.

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?

How much extra revenue is infection control making for a hospital?

One of the challenges infection preventionists face is convincing hospital executives the value of their work, in terms of dollars saved for the hospital. In almost every hospital, infection control is considered a cost center. This perception makes it difficult for IPs to obtain new resources and during times of economic hardship, infection control budgets are often ones that get cut first.

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.

SHEA Guideline

APIC Update

There are so many interesting talks at APIC that there is not enough time to digest it all. A couple topics that I want to expand on in later posts (but want to mention in this post) are 1) How IPs can reposition their roles and their department as revenue centers as opposed to cost centers and, 2) Controversies on hand hygiene compliance, and 3) NOLA cuisine.

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.

Atul Gawande Keynote at APIC this morning

Sat in Atul Gawande's keynote at APIC this morning. His focus was on the role of infection control, and he of course discussed in-depth the checklist movement and how it can be applied even beyond infection control. Presented his experience as he followed Brigham and Women's IP Debbie Yokoe around to see the hospital through the eyes of an infection preventionist. Some highlights from the keynote:

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%.

Just-in-Time Healthcare

Yesterday's New York Times had an article on the application of Kaizen, or Continuous Performance Improvement (CPI) principles at hospitals to reduce cost and increase efficiency. As a Six Sigma enthusiast, I was excited to see that the same concepts that have been used in manufacturing is making its way into healthcare and hospitals are reaping benefits from CPI practices. Hopefully more hospitals will adopt these principles and that one day we will achieve Just-in-Time Healthcare.

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!

Vecna Medical Team at APIC - Booth 1107

The Vecna Medical team has arrived at APIC in New Orleans! We braved the rain and the thunderstorm to set up the booth, and we're ready to attend and participate tomorrow.

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.

Class I Recall of Cepheid’s Xpert MRSA/SA Blood Culture Assay products for use with GeneXpert Dx System

As reported on fda.gov, “The firm received increasing numbers of complaints for false negative MRSA results when compared to MRSA positive results received from culture methods. All Cepheid MRSA/SA Blood Culture Assay products have a potential of generating infrequent rates of false negative MRSA results, which could result in incorrect treatment or delay of care for patients with MRSA infection.”

“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.

Bigger Brains by Busting Bugs

Reducing and preventing infectious disease leads not only to healthier populations, but also to smarter ones, says a paper recently published in Proceedings of the Royal Society. It’s been previously shown that there is a global variation in intelligence, and that richer, more developed countries have higher average IQs. The paper analyzes several possible factors in this variation, and comes to the conclusion that prevalence of infectious disease is the best predictor of average national IQ.

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

MDROs in agriculture

Humans aren't the only ones battling multi-drug resistant organisms (MDROs), wheat, as it turns out, is also susceptible to fast evolving infectious superbugs. A story on the wheat rust in last week's Economist reminded me of our ongoing battle with MDROs.

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.

http://www.economist.com/node/16481593?story_id=16481593
http://en.wikipedia.org/wiki/Wheat_leaf_rust

Antimicrobial Resistance: Tragedy of the Commons

Over the past few years, many in the infection control community have identified global antimicrobial resistance as the classic economic problem known as ‘tragedy of the commons.’ Tragedy of the commons refers to the situation in which many uncoordinated players, acting in their own self interest, deplete a limited shared resource. Seminal examples include overfishing the ocean and global warming.

Antimicrobial resistance is similar in that health care providers and patients, acting in their own self interest, behave rationally and consume increasing amounts of antibiotics. This drives the unintended, adverse result of increasing antimicrobial resistance, compromising the efficacy of those same antibiotics. 60% of staphylococcus aureus in the US and UK are methicillin resistant. Multi-drug resistance pathogens are emerging in developing countries partially as a result of antibiotic overuse.

Recognizing that antimicrobial resistance is a global economic problem as well as a public health problem better informs strategies and solutions. We begin to think of antibiotic efficacy as a shared limited resource - like the environment and the world's fisheries, and can exercise innovative solutions to promote desirable behavior. Here are experts who've framed the problem in this way:

The tragedy of antimicrobial resistance: achieving a recognition of necessity

Antibiotic Overuse: The Influence of Social Norms

The sounds of silence: Public goods, externalities, and the value of infectious disease control programs

Monday Readings

I want to share two articles from yesterday's New York Times and Wall Street Journal. The first piece from the NY Times talks about FDA's new policy proposal to limit the use of antibiotics in animal feed. There is an apparently an on-going battle between public health and agriculture over the use of antibiotics in animal feed. The prevalent use of antibiotics such as penicillin and tetracycline in water and feed increases the emergence of resistant bacteria, which many believe to be an important public health issue. FDA's new policy calls for limited use of antibiotics. Whether or not the policy can be passed into law remains to be seen.

The second article from the Wall Street Journal describes quantitative measures implemented by many businesses, including hospitals, to evalute performance of employees. The article uses Long Island Jewish Medical Center as an example. Instead of evaluating nurses on qualitative metrics like "leadership" or "respectfulness," the hospital adopted a computer-based performance system that evaluates nurses against quantifiable goals such as keeping infection rates low and patient-satisfaction scores high. One of the key drivers behind the change is that insurers will begin paying hospitals for care based in part on patient satisfaction, which will be collected by surveys after patients are discharged. So hospitals are aligning performance measures to financial incentive.

http://www.nytimes.com/2010/06/29/health/policy/29fda.html
http://online.wsj.com/article/SB10001424052748703964104575334832074865058.html?mod=WSJ_hpp_sections_careerjournal

Emerging technologies in infection control

Infection Control Today published an article detailing several emerging HAI prevention technologies this week. All were interesting, but a few really stood out to me:

1. HandGiene - This company developed an automated hand hygiene technology that uses RFID, wireless, web-based data collection and reporting software to provide real-time monitoring for handwashing activities of healthcare personnel. Given that many believe that more than 50% of all HAIs could be eliminated by handwashing, HandGiene has great potential to help hospitals reduce HAIs through higher hand hygiene compliance rates.

2. Activeion - Activeion's flagship product, the Ionator, uses a process called "irreversible electroporation" to kill germs and bacteria in tap water. The process does not require the use of chemicals and therefore is very environmentally friendly. The company has a cool video that shows how the process works.

3. Agion - I came across this company a couple of years ago. The company makes disinfectants using silver. One of their products, AgionSilverClene24, provides an attractive alternative to traditional surface disinfectants because it keeps surfaces clean longer and is effective against tougher bugs such as MRSA, VRE, HIV, and Influenza.

Finally, I attended the MIT 100K Business Plan Competition Final last month and this year's second place winner is a company called Novophage. They have engineered a bacteriophage that slows the evolution of antibiotic resistance in bacteria and thereby delays the onset of antibiotic resistance. The bacteriophages could be used in conjunction with traditional antibiotics to improve efficacy.

Connected

I’ve been reading the new book Connected by Nicholas Christakis and James Fowler that provides a take on public health through the lens of social network analysis. Christakis and Fowler introduce the “Three Degrees of Influence Rule” that claims we influence and are influenced by people up to three degrees separated from us, a majority of whom we do not know. Several studies have shown, in addition to communicable diseases, conditions such as depression, hysteria, infectious laughter, and even suicide can spread surprisingly quickly through social networks. Particularly relevant to infection control and epidemiology, they described how fellow researchers used the movement of currency, data, and phone calls to predict the movement of pathogens like SARS globally over the course of a several days. The pattern identified was a Lévy flight characterized by many short legs followed by a small number of long legs.

It’s an interesting book that has a few case studies relevant to infection control and many that are analyzed using similar principles (elections, stock markets, video games). Some food for thought and a potential intersection where those in the infection control profession and those in other professions (marketing, economics, and politics) can share ideas and interventions. Connected shows how materials, ideas, and conditions can spread in a similar fashion to infectious disease.

MRSA and survival

Dr. Dan Diekema recently blogged about a new study published in JAMA that shows that respiratory tract MRSA carriage/infection is linked to high mortality in cystic fibrosis patients. He raises an interesting question about why MRSA, and not MSSA, is associated with worse outcome among cystic fibrosis patients especially since there is no evidence to show that MRSA is intrinsically more virulent than MSSA (Now, this is debatable as there are studies that show that MRSA is more virulent than MSSA, however the justifications behind why this is the case are controversial).

Nevertheless, Dr. Diekema’s question reminded me of an article I read on toxoplasma in last week’s Economist. Toxoplasma is a pathogen that’s a close cousin to Plasmodium, the bug that causes malaria. However, despite its high prevalence, symptoms among people infected with toxoplasma are mild and the bug doesn’t seem to cause a lot of damage, UNTIL scientists discovered that rats infected by toxoplasma exhibit more risky behavior, which suggests that the bug is interfering with the brain.

A separate study on toxoplasma in humans found that people involved in road accidents were almost three times more likely to be infected by toxoplasma than those who had not been. Some are going as far as saying that toxoplasma is altering the culture of entire societies.

So, here is my theory to answer Dr. Diekema’s question, maybe MRSA is affecting patients’ psychology and/or behavior in a way similar to that of toxoplasma? Or could it be that MRSA colonization/infection leads to higher susceptibility to toxoplasma infection, which leads to more risky behavior? i.e. not following hand hygiene compliance. I wonder what kind of study we can do to prove my theory.

First Steps in Our Journey to Zero

It is tempting to declare the “moral equivalent of war” against such global challenges as global warming, oil spills, and healthcare-acquired infections. The metaphor compels and intrigues because it unites disparate parties, focuses them on a singular goal, and demands appropriate resourcing. Many call for a “Manhattan Project-style” effort (referring to the WWII era project that resulted in the creation of the first nuclear bombs) to discover elusive solutions to longstanding problems. In the world of infection prevention, the problem of 99,000 deaths and 1.7 million healthcare-acquired infections annually is one that requires the collective energy of researchers, health care workers, and governments.

We opt, however, for the metaphor of a long journey. The problem is massive and it will require unity, focus, and resources. However, arriving at lower infection rates and establishing an improved patient safety culture will figuratively require us to “be at a different place”. A safe health care system with minimal levels of healthcare-acquired infections will look much different than where we are today.

In the midst of all this, we are already taking the first positive steps. HHS Secretary Sebelius recently declared an early victory with the news of an 18 percent decrease in national CLABIs in hospitalized patients. Success stories such as that in the state of Michigan also bode well for long-term success.

The purpose of this blog is to document our collective journey to zero HAI-related deaths. We’ll explore the varied and innovative efforts of individuals, groups, and governments. We’ll build a supportive virtual community to share best practices, provide moral support, and collaborate. Dr. Atul Gawande of Brigham and Women’s Hospital in Boston recently characterized the HAI problem as “the easiest 100,000 lives we can save.” We share Dr. Gawande’s optimism, and we are excited to document the successes, stories, and challenges in our collective journey.

APIC’s MRSA Census Coming to Your Hospital

How big of a threat is MRSA to hospitals? The recently released APIC survey attempts to answer just that.

MRSA, or Methicillin-resistant Staphylococcus aureus, is responsible for an estimated 19,000 deaths a year in the U.S. and costs hospitals an additional $60,000 per patient who acquires a MRSA infection in the hospital. In October 2006, APIC conducted the first-ever national MRSA prevalence study and found that 46 out of every 1,000 patients in the study were either infected or colonized with MRSA. The rate was larger than previously estimated and led to several concerted efforts by APIC to combat MRSA. The goal of this year’s survey is to update the study results with the current MRSA prevalence rate. The comparison will help evaluate the impact of recent MRSA prevention measures on MRSA prevalence.

The Centers for Medicare & Medicaid Services (CMS) has not yet begun to penalize hospitals with high MRSA infection rates by reducing reimbursement. However, given the current trend that focuses on pay-for-performance, it’s likely that CMS will refuse to pay for preventable MRSA infections in the future.

Therefore, I urge every hospital to participate in this important survey. After all, how do we fight MRSA if we don’t know what kind of problem we are dealing with? The survey results affect the measures and solutions we adopt, the amount of resources we need and receive, the type of care we provide to patients, and the kind of research and innovation that will be necessary to combat the infection.

APIC MRSA Survey