Monday, March 2, 2015

SHEA Spring 2015 Conference - Back to the Future!

Wanted to give you all a quick update as we edge ever closer to SHEA 2015 in Orlando. As many of you know, SHEA 2015 has a new format - closer to 2011 and earlier SHEA meetings. Specifically, we will have HAI-focused scientific abstracts  - both posters and podium presentations. This year, we accepted ~250 top-notch abstracts and 41 will be delivered as podium presentations. Very exciting!


1) Registration has already exceeded 2014 - register now to get the best (closest) hotel rooms
2) There are eight oral abstract sessions including ones on SSI, Hand Hygiene and Contact Isolation, MDR-GNR, CDI, Devices and Public Reporting, MRSA and Emerging HAI-Pathogens, and Long-Term Care. 
3) This year we will have a Top Abstracts in Hospital Epidemiology session. The top 5 abstracts will be presented on Sunday morning.  Don't miss that session - some really great studies.
4) The meeting will still contain the highly successful and popular SHEA/CDC Certificate Training Course in Healthcare Epidemiology. You just select that you will attend the course when you register.
5) NEW THIS YEAR: SHEA Certificate Course in Post-Acute and Long-Term Care Track. This 2-day course (Thursday and Friday - May 14th and 15th) will provide an up-to-date review of the latest epidemiology of HAI in LTC and you'll also get a SHEA Certificate for taking the course.
6) THERE WILL BE SNACKS - breakfast, lunch and snacks are included with your registration.

See you May 14-17, 2015 in Orlando!

Image source: SHEA 2011 Meeting from Infection Control Today.

Tables and Chairs (There Will be Snacks at SHEA): Andrew Bird

best SHEA-specific lyric: "Just don't let the human factor fail to be a factor at all"

Friday, February 20, 2015

Drug resistant bacteria versus advanced medical technology: No contest

The duodenoscope implicated now in several deadly outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) is an otherwise terrific device for management of biliary or pancreatic duct disorders. Unfortunately, the same features that allow the scope to guide fine instruments into miniscule spaces also provide sanctuary for bacterial pathogens, protecting them from all standard approaches to disinfection. To quote yesterday’s FDA safety communication
“…reports associate multidrug-resistant bacterial infections in patients who have undergone ERCP with reprocessed duodenoscopes, even when manufacturer reprocessing instructions are followed correctly. Meticulously cleaning duodenoscopes prior to high-level disinfection should reduce the risk of transmitting infection, but may not entirely eliminate it.”
Translation: you pays your money and you takes your chances. 

There aren’t any great options for further reducing the (albeit small) risk for infection transmission from these devices. Some hospitals that have experienced outbreaks have switched to ethylene oxide gas, which is time-consuming and may still fail if organic debris remains in the tiny spaces that are so difficult to clean mechanically. Microbiological surveillance (culturing scopes after disinfection) is time-consuming, costly, and has unknown sensitivity for detection of transmission risk. 

This problem is just one example of the limitations that antimicrobial resistance and infection control practice place on advanced healthcare delivery. Each year we see advances in our ability to provide life-saving care—but each of these advances can be easily circumvented by a simple lapse in infection control practice, or an untreatable bacterial pathogen. 

As for this particular device, there must be a safer approach that doesn’t sacrifice utility. In a world where you can buy a robot hat-backpack that feeds you tomatoes while you jog, there must be a way to design a duodenoscope that can be effectively cleaned.

Tuesday, February 17, 2015

Numbers Matter: Why counting only resistant bacteria ultimately harms our patients

You've seen the numbers. The CDC estimates that 23,000 deaths are caused by antibiotic resistant pathogens annually and as many as 14,000 of these deaths are linked to C. difficile. Every time I look at those numbers, they make me incredibly sad. First, they include all C. difficile deaths and not just those attributed to fluoroquinolone-resistant C. difficile, for example. This tends to incorrectly overweight the importance of C. difficile relative to other pathogens. Second, and you've heard me rant about this before, they only count deaths caused by the small proportion of bacterial pathogens that happen to be resistant, as narrowly-defined. This would tend to diminish the importance of bacterial pathogens compared to other causes of death (e.g. accidents). But I'm getting ahead of myself.

The numbers I'm about to throw at you are very rough estimates. I'm using these estimates to illustrate a point and hope that others will eventually provide more accurate estimates. If you think I need to correct a specific number, let me know in the comments, and I'll do my best to make the change - but I'm not promising. 

Let's take S. aureus as an example. The CDC estimates that 80,000 infections and 11,000 deaths are attributed to MRSA each year. In 2005, they also estimated that MRSA was associated with 18,650 deaths, but I'll be conservative and stick with 11,000. Per this 2013 NHSN report, the proportion of S. aureus that were MRSA ranged from 43.8% (SSI) to 58.7% for CAUTI. I'll use the lower proportion (44%) since this allows for some mortality secondary to more community (less MRSA) infections. However, I suspect most patients that die from S. aureus infection will ultimately be hospitalized. For simplicity, I will also assume that MRSA is twice as lethal as MSSA (AKA penicillin-resistant S. aureus).

Taking the above numbers, if there were 80,000 MRSA infections, we would expect 102,648 MSSA infections. If the mortality rate for MRSA was 13.75% (11,000/80,000) then MSSA's mortality rate would be half of that or 6.875%. So there would be 7057 deaths from MSSA. If you add that to the 11,000 you get 18,057 deaths due to S. aureus. We can quibble about numbers, but I suspect that 7,000 deaths caused by MSSA, passes the so-called giggle test.

Thus, if we used the CDC rankings to fund research and prevention activities, we would rank C. difficile at the top of the report. However, if we used my ranking system, S. aureus (MSSA+MRSA) ranks ahead of CDI. Since most interventions to prevent MRSA deaths would also work against MSSA (vaccines, new antibiotics) shouldn't both types be included in burden of disease estimates? The imbalance gets worse when you look at Gram-negative infections. Do we really only care if grandma dies of the 2-12% of E. coli or Klebsiella that are resistant to carbapenems? Do we really only count the 610 deaths from CRE and 1700 from ESBL? Clearly it would be better if we counted all deaths from E. coli and Klebsiella and projected a future where almost all strains would be ESBL or CRE.  This would allow us to make better decisions regarding current and future research priorities and prevention efforts.

I suspect if the S. aureus mortality estimate jumps from 11,000 to 18,000 when counting MSSA, it's not a stretch to imagine that deaths from bacterial infections would approach 100,000 in the US. If we count attributable mortality appropriately, deaths from bacterial infections would be a top 10 cause of death in the US. Top 10 means more money for research and prevention. Let's get these numbers right - grandma is counting on us.

Monday, February 16, 2015

Ask your doctor

No introduction needed apart from John Oliver - Marketing to Doctors. If you'd like to search for a specific physician or hospital, the CMS Open Payments site is now online. If you're interested in viewing the COI policy that covers "your bloggers", you can see it here.

Thursday, February 12, 2015

Hijacked! A new form of predatory publishing

The rise of predatory open-access publishing is well documented. These charlatans will take your money and publish literally anything you submit (most famous example here).

Today I learned of a relatively new form of predatory publishing, the wholesale hijacking of a journal’s identity. See below for the text of an email soliciting articles for the Journal of Clinical Microbiology (JCM)—except the sender has no affiliation with JCM, the website is not the JCM website, etc. It’s basically a journal equivalent of identity theft, soliciting articles under false pretenses and publishing anything as long as the author coughs up cash. According to Beall’s list, there are only 30 instances of this practice as of January 2015 (compared with almost 700 predatory publishers and over 500 standalone predatory journals). In this case, the hijacker may have been unwitting--just combining the word journal with "clinical microbiology" without realizing that JCM even exists.

One bit of advice to hijackers: when moving the scam forward, probably best not to include members of the actual journal’s editorial board in your email solicitations.

Wednesday, February 11, 2015

The Power of Poop

If you needed even more reasons to move to Iowa, you now have another - an HAI-related Grand Rounds by esteemed co-blogger Mike. I might have gone with Tao of Poo(h), but who can ignore Poop's Power?

Update: Webcast (audio + slides) of the talk is now available.

Sunday, February 8, 2015

Clamoring for CLAMBI

Last month we blogged on updated NHSN surveillance definitions and we bemoaned the fact that CLAMBIs (central line associated mucosal barrier injury bloodstream infections) are not being separated from CLABSIs for public reporting, and more importantly for the CMS pay-for-performance programs. These infections are particularly common in patients with hematologic malignancies, are due to the translocation of enteric flora into the bloodstream, and unlike true CLABSIs are not preventable. A new paper in Infection Control and Hospital Epidemiology from Northwestern University demonstrates why this is important.

All cases of CLABSI were identified over a 14-month period on 2 inpatient hem/onc/BMT units (72 beds). The cases were further subdivided into "true" CLABSIs (i.e., not associated with mucosal barrier injury) and CLAMBIs. A total of 66 infections were identified, of which 47 (71%) were CLAMBIs. E. coli, enterococci and viridans streptococci accounted for 62% of the pathogens isolated.

The authors note that at the present time CLABSIs identified outside of ICUs are not publicly reported nationally; however, the CLAMBI patients spillover into ICUs. At Northwestern, 12% of ICU CLABSIs were determined to actually be CLAMBIs.

Is it any wonder that tertiary care hospitals are disproportionately affected by CMS penalties? This is just one of many reasons.