CDC goes OOPS!

How does the CDC really feel about infection control?  Perhaps we can get a hint by looking at the cover of their new Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.  How many fundemental breaks with basic infection control do you see? I guess we know there is a new low in minimum expectations!

Oh, by the way, the CDC has just released their new Guide to Infection Prevention for Outpatient Settings.

h/t Jan Kluytmans

CDC finally addresses zombie threat

The CDC is getting a lot of media attention for finally turning their attention to zombie preparedness. As regular readers of this blog know, we called for decisive action (and the development of a rapid screening test) almost two years ago. I’m not sure what took the CDC so long to address this threat head-on. Rest assured, dear readers, that we’ll stay on the zombie beat and alert you immediately to their emergence. Our goal? Zero zombies.

Dr. David J. Sencer, a “public health giant”

Dr. Sencer was CDC director during smallpox eradication, the swine flu episode, and the discovery of the cause of the respiratory infection outbreak at the American Legion convention in Philadelphia in 1976. He was also the New York City health commissioner during the early years of the HIV epidemic. He died on Monday at age 86. According to Dr. Tom Frieden, he stayed involved at CDC until very recently:

"At the height of the H1N1 pandemic of 2009, he was here full time, and I said, ‘Can I pay you?’ He said, ‘No, this is a labor of love.’"

NY Times obituary
Photo by William E. Sauro, The New York Times

Set your TIVO: Animal Planet's Killer Outbreaks

A new Animal Planet series called "Killer Outbreaks" starts April 15th.  The 6-episode series features CDC experts and covers Anthrax, E. coli, Hantavirus, Rabies, West Nile, Monkey Pox, Acinetobacter baumannii, Salmonella, Valley Fever, Meningococcal Disease, SARS and MRSA.  It airs each Friday at 10pm ET and 10pm PT. Doesn't get more exciting than that!


CDC Press Release 4/12/2011

Go Epicenters!

The CDC just announced ongoing funding of the Prevention Epicenters (PE) program. You can read John Jernigan’s post at Safe Healthcare for the details. We have been involved in this program in the past (the University of Iowa participated during the first two rounds, and both Sloan-Kettering and Maryland were Epicenters while Eli was in those locations). Loreen Herwaldt worked with our Iowa group to put together a great application for this round. Alas, we fell short—but to a group of sites with real depth in the science and practice of healthcare epidemiology.

Collaborating within a multicenter research consortium has its challenges, and progress often seems painfully slow. It’s impressive, then, to look at the body of work that has come out of the PE program, especially given the shoestring budget from which it has been funded. Ten million dollars sounds like an awful lot of money, but spread over 5 centers (each of which represents a healthcare system) and 5 years, minus the institutional overhead, it doesn’t leave much to do studies that might lead to new insights in prevention. Too often this means scaling down prospective interventional trials into less-definitive-but-still-valuable observational studies, simply for want of funds.

Stacked against the morbidity, mortality and cost of health care associated infections, HAI prevention research is massively underfunded. The PE program is a great example, but should be scaled up 10-100 fold.

Pathogen-specific preventability?

As Mike pointed out yesterday, one of the interesting findings in the CDC CLABSI report is the difference in percent reduction by pathogen. The most dramatic reduction (73%) was found among Staphylococcus aureus, with more modest reductions among gram negative bacilli (37%), Enterococcus spp. (55%), and Candida (46%).

These findings, discussed in some detail in the MMWR report itself, are consistent with a point I made in a prior post on the preventability of CLABSIs. The CLABSI prevention bundle elements prevent infections due to organisms that gain access to the bloodstream from the catheter-skin interface. No amount of skin preparation, site care, sterile barriers and hand hygiene can prevent organisms from translocating across the gut wall of a seriously ill patient—and so far, no one has developed catheter material that can completely prevent such organisms from adhering once they do gain access to the bloodstream. Furthermore, many of the organisms that arise from gut or other peripheral sites will be misclassified as CLABSIs even if they never adhere to the catheter.

We should expect that interventions which focus on reducing bacterial burden at the catheter insertion site will have their greatest impact on skin bugs, and their least impact on common gut flora. As for getting to zero, it won’t happen until we have ways of addressing infection sources other than the catheter insertion site (and by “addressing”, I mean both improved prevention approaches and improved definitions).

Only 48 million get food poisoning annually in the US

Good news (not really). Through an estimate derived through 'substantially improved methods', the number of people who are thought to get sick annually via food poisoning fell from 76 million to 48 million.  That's fantastic. Annual deaths fell from 5000 down to 3000.

The two reports on illness due to major recognized pathogens and unspecified agents along with an editorial by one of my Maryland mentors, Glenn Morris, have been published in expedited form in EID.

I hope the timing of the article doesn't impact the bill modernizing the FDA that recently passed  in the Senate but has yet to make it to President Obama. 48 million and 3000 are too many, especially in 2010.

Ominously, Glenn Morris points out in the editorial that "if one looks simply at rates of overall gastrointestinal illness in the United States, based on FoodNet Population Surveys, one might infer that overall rates of acute gastrointestinal illness have increased during this period, from 0.49 episodes per person per year in 2000–2001, to 0.54 in 2002–2003, and to 0.73 in 2006–2007."  On the plus side. Morris suggests that using FoodNet data "the overall trends show an initial drop in incidence of infection with the major bacterial foodborne pathogens after implementation of the 1995 USDA regulations, followed by a leveling off of incidence in subsequent years."

Well, there is some good news.  We now have more accurate estimates of infections due to foodborne pathogens in the US. When you have better data, you can have a a more modern, risk-based food safety system.  This is why Dan and I argued in our recent JAMA editorial that we need a continued expansion of the existing but somewhat limited hospital-infection and MDRO surveillance system in the US.

see also: William Neuman NY Times article

CDC's Get Smart for Healthcare program

Arjun Srinivasan, Medical Director for CDC’s “Get Smart for Healthcare” campaign, and Ramanan Laxminarayan, Director of Extending the Cure, co-authored a recent piece in the Health Care Blog. It describes the current crisis with carbepenem-resistant Enterobacteriaceae and how the CDC and partners are responding. For example, this week, they launched the “Get Smart for Healthcare” program which complements the existing “Get Smart: Know When Antibiotics Work” program. I will let you read what Arjun and Ramaman have to say...

link: The Health Care Blog

h/t: Mark Vander Weg

Post #610: Happy "Get Smart About Antibiotics Week" (November 15-21, 2010)

Man, have we done a lot of posting in the past 1.5 years.  I think Dan and Mike will agree with me here when I say that none of our posts have been as important as this one.  None.  The reason for this is that I'm announcing a whole 7 days of celebrating and not just one day. The world has witnessed Global Handwashing Day,  World Hand Hygiene Day, and World MRSA Day this past year.

But notice, these were just on single days.  Thus, we can officially announce that the smart use of antibiotics is 7 times more important than MRSA and 7/2 or 3.5 times more important than the domain of handwashing/hand hygiene. These are two questions that as an epidemiologist I've been struggling to answer for 10+ years and now I finally know.  While it is true that this is the 3rd annual "Get Smart About Antibiotics Week" and I should have officially known this two years ago, I do like to wait for "replication of results" or reproducibility before drawing a firm conclusion on such important questions. Alright everybody, get ready and Get Smart about antibiotics!

In it to win it

Good news going into the weekend: the CDC just declared Healthcare Associated Infections (HAIs) to be one of their first six “Winnable Battles”. They have coined this term to describe “public health priorities with large-scale impact on health and with known, effective strategies to intervene.”

I hope this leads to more resources—not just for implementation but for novel prevention research. As we’ve pointed out before, there is more than one view of what it means to “win” the war on HAIs. By one assessment, we already know how to prevent HAIs. All we need to do is implement this knowledge and such infections will drop to zero (and if they don’t, we can finesse the definitions until they do!). A more nuanced view is that our current prevention strategies are effective, but only against the subset of infections those strategies target. That is, there are still infections that cause harm and for which we do not currently have effective prevention strategies. These differences in perspective are also well illustrated by Mike’s earlier post on hospital epidemiology and quality improvement.

Where you fall on this continuum makes a big difference in terms of where you’d like to see more resources. Should they be devoted primarily to implementation of existing strategies (and to “implementation science”), or to research addressing novel approaches to infection prevention? (I realize that the correct answer is "both". But resources, sadly, are not infinite)

*motivational poster image courtesy of Despair, Inc.

MRSA in decline

Today’s news is the JAMA publication of CDC surveillance data showing a steady decrease in healthcare-associated MRSA infections from 2005-2008. Eli and I wrote the accompanying editorial, so I refer you to that for our commentary on this. We may have more on this later.

JAMA article
Our editorial
NPR story (click link to listen)
Reuter’s Health story

The CDC has a brand new blog

And I like it! I especially enjoyed the post by our own Phil Polgreen, which features his iScrub application. Alex Kallen also has a nice recent post on prevention of CLABSI outside the ICU, which is a topic overdue for attention.

However, I did wince when I read about this event:

“I believe in zero CLABSIs!” shouted a group of 3,400 APIC Annual Conference attendees at the conclusion of patient-safety leader Dr. Peter Pronovost’s opening session.

Why does this make me uncomfortable? It isn’t because I haven’t bought into the power of CLABSI prevention efforts—we have units whose efforts have pushed CLABSI rates to zero for months at a time, and we celebrate that. I also think that most infection preventionists (IPs) understand the difference between a rah-rah, go-get-‘em, “aspirational” BHAG on one hand, and a realistic assessment of what is preventable on the other.

The problem is that many people don’t understand this difference. Among them are fellow healthcare workers, hospital administrators, reporters, the general public, third-party payers, and malpractice attorneys. To them, 3400 infection control experts witnessing to their belief in zero CLABSIs means that every CLABSI must be preventable, and therefore that every CLABSI represents an unconscionable breach of practice. We’ve blogged before about some of the potential unintended consequences of the “zero” paradigm. Fudged definitions, antibiotic overuse, pitched battles between unit personnel and IPs over every device-associated infection, and an atmosphere of blame and punishment, just to name a few.

The fact is that not every CLABSI is preventable. Most are, but not all. Even Peter Pronovost’s hospital's ICUs, though they have wonderfully low rates, still experience CLABSIs. If we follow perfect processes of care, we should be able to prevent those infections that arise from around the catheter insertion site, and those that are introduced exogenously. But what about those arising from gut translocation of bacteria in a critically ill patient? Even the most aggressive gut decontamination regimen (which will inevitably accelerate antimicrobial resistance rates) won’t be able to prevent organisms from gaining access to the catheter in this way.

We should be able to mobilize the troops to drive CLABSI rates to their irreducible minimum without setting unachievable goals. I do admit that “getting to zero” is a catchy phrase, though, and very well-suited to campaigning for lower infection rates. The theme I proposed for our latest CLABSI prevention campaign was roundly rejected….and I still don’t understand what was so wrong with: “Zero Is Great, But One Every Few Months Is Pretty Darn Good, Too”.

Empowering patients to ask providers to wash their hands

"2000 miles

Is very far through the snow

I'll think of you

Wherever you go"
- Chrissie Hynde

We moved our family to Iowa City last week. There is something about being back in the Middle West that gets me singing old Pretenders' songs. I can't really explain it. One thing I've immediately noticed is that people say "hand washing" here and not "hand warshing" like I heard often back east.

Enough of that. There is a qualitative study out in the June issue of the Journal of Patient Safety by Amanda Garcia-Williams and colleagues from the CDC's DHQP that assessed the CDC video "Hand Hygiene Saves Lives" as a tool of patient empowerment. They conducted four focus groups using laypersons without hospital exposure in the past year, laypersons with hospital exposure, nurses and physicians. There are a lot of interesting findings within the study and many should be subject to further analysis.

The primary finding was that laypersons were much more likely to ask a nurse to wash his/her hands after watching the video, however, those with recent hospital exposure stated that they would still be "nervous" or "scared" to do so. Interestingly, laypersons with hospital exposure were more likely to ask physicians to wash their hands after watching the video but those without hospital exposure were not influenced by the video to ask physicians to wash their hands.

A very interesting finding was that laypersons with hospital exposure had lower levels of perceived risk for HAIs than persons who hadn't been in the hospital recently. Perhaps fear of the unknown is playing a role here. I suspect this fear could be used positively to get them to monitor compliance among their healthcare providers. Overall, I found the results of this study promising. Hopefully they will continue to analyze the impact of this video through quasi-experimental study or using other methods to see if this video intervention actually results in changed patient behavior, improved hand hygiene compliance, and dare I dream, reduced HAIs.

Article in the Journal of Patient Safety (here)

New CDC proposed guidance for influenza control

CDC recently posted proposed guidance on prevention of seasonal influenza in the healthcare setting. Written comments on the proposed standards will be accepted through July 22, 2010. The intent of these guidelines is to replace prior CDC infection control recommendations for seasonal and H1N1 influenza. In a nutshell, CDC is proposing droplet precautions, except when aerosol generating procedures are being performed, in which case airborne precautions should be followed. To see the document click here.

17 states report CLABSI rates. Why only 17?

The CDC just released the First State-Specific Healthcare-Associated Infections Summary Data Report, which focuses on CLABSI. HHS press release is available here. Needless to say, we are all disappointed with the rates here in Maryland given how hard the State and hospitals have worked at preventing these infections. No one seems more disappointed than Peter Pronovost. No excuses.