A note on flackery.

I believe in transparency (see Operating Instructions in the right-hand column), and some comments have been submitted to the blog recently that I was not willing to publish. So it's time to declare a policy.

Here it is: I will not allow any comments that advertise any products, explicitly or by linkage, period full stop.

I am my readers' filter; that's the responsibility I accepted when I started this blog, and I take it seriously. So anything that might be published in this space goes through me first. If anyone out there has a product — pharma, natural, alternative, antibacterial, whatever — my email is on the right. Send me a note, send me some literature; especially send me some data. I'm happy to engage offline.

I may post on what you send, or I may not. But it will be my post, not someone else's cloaked advertising. Just so we're clear.

Sermon over. Donuts and coffee, anyone?

Maybe we just build them better? (But who pays?)

OK, campers, I know I'm tossing crumbs here, but I drove 6 hours today and am now, umm, well, not in any major metropolitan area, that's for sure. But I'm visiting a very interesting hospital program tomorrow. And my chain motel is smack-dab between a Denny's and a Waffle House. Just think of the breakfast options. (And imagine my arteries clogging. OK, don't.)

Skittering back to the reason why we're here: Via the LA Times, an intriguing article about the possibilities of reducing hospital-acquired infections by designing hospitals better: single rooms, improved airflow, more sinks, etc.

"Private rooms are the most important design element that reduces the spread of infection between patients," says Richard Van Enk, director of infection control and epidemiology for Bronson Methodist Hospital in Kalamazoo, Mich. Bronson is a pioneer of evidence-based design and was among the first hospitals in the United States to build a facility with all private patient rooms.
The hospital's new design also incorporates two sinks in each patient room, one of which is dedicated for the exclusive use of the healthcare worker. Many easily cleaned surface materials such as water-based low VOC (volatile organic chemical) paint, plastic counter coverings and linoleum floorings with antimicrobial properties were also used throughout the hospital. (Byline: Lisa Zamosky)

It sounds plausible to me. Superbug Spouse is an expert in human-factors design, and we both do photography and web design (he's better), so issues like this - which way do your eyes go? what button do you naturally want to push? - get tossed about a lot in our house. And just yesterday I listened to an infection-control nurse describe the difficulty of getting healthcare workers to use sinks in older rooms in which the sinks are within the bathrooms; the HCWs perceived the bathrooms as the patients' private space, not as accessible to all. So there may be something to this.

But retrofitting is expensive. And the bill will be paid by... ??

Limiting prescriptions - can it be done, will it help?

I'm on the road reporting for two weeks, which makes keeping up with MRSA news fairly challenging. (Hangs head in shame, promises to do better in August when I will be chaining myself to my computer in vain hope of meeting a manuscript deadline.)

Meanwhile, here is a tidbit of news on the MRSA front, from the UK. As our international readers will know (oh yes, we have them, Google Analytics makes a very nice map - hi, London! say hello, Rotherham!), MRSA has been a ferocious hospital pathogen in the UK, but community strains have been less problematic there until recently.

The National Institute for Health and Clinical Excellence, an agency that does cost-benefit analysis on behalf of the National Health System, has asked doctors to limit prescribing antibiotics for most of the upper-respiratory infections they see in private practice on the assumption that most URIs will be viral and therefore not helped by antibiotics anyway.

...Doctors in the state's health system should not prescribe antibiotics for most cases of sore throats, colds, bronchitis or other types of respiratory infections, the National Institute for Health and Clinical Excellence, or NICE, said.
They should also delay writing such prescriptions and reassure people the drugs are not needed immediately and would make little difference because most respiratory infections are viral, the new guidelines said. ...
The drugs watchdog said a quarter of people in England and Wales visit the doctor because of respiratory tract infections, which account for 60 percent of all antibiotic prescriptions in general practice. (Reuters, byline Michael Kahn)

Note that this is a guideline, which is to say voluntary — though because it is promulgated by a regulatory body within a single-payer health system, may well have more force than similar guidelines that have been promulgated in the US by professional societies such as the Infectious Diseases Society of America. This article from IDSA from last April captures how effective guidelines have been here. Answer: Overall, not much, because they are a matter of asking, not compelling.

I'm interested in hearing from any readers who have experience with antibiotic stewardship programs at the society level or in institutions: Do they work, what does it take to implement them, how draconian do you have to be? If anyone can offer thoughts, please comment or send me a private email to the address in the right-hand column.

On to North Carolina.

Please route to the Dept. of Unintended Consequences.

Via the open-access Journal PLoS One, an unnerving report of Canadian researchers finding fluoroquinolone resistance in E. coli in a group who are vanishingly unlikely to have ever taken a quinolone: indigenous Indians in isolated villages in the Guyanese rainforest.

For most people the most familiar quinolone is likely to be ciprofloxacin (Cipro), a very valuable antibiotic in the arsenal because it works against a broad array of Gram-positive and Gram-negative organisms and is off-patent and therefore relatively inexpensive. (Cipro became a household word in the US during the anthrax attacks — it is given prophylactically on suspicion of exposure to inhalational anthrax — and was recently given a "black box" warning by the FDA because of an association with tendon ruptures.)

Quinolone resistance has certainly been recorded: In 2003, a team found 4.0 percent of E. coli in US intensive care units were resistant to cipro. The Canadians — 20 volunteer medical personnel from Ontario — found 5.4 percent among the Guyanese. That's in a setting where there is no selective antibiotic pressure, because no one is taking antibiotics.

Aha: But they are taking malaria prophylaxis, including the extremely common and cheap antimalarial chloroquine. The team theorizes that chloroquine is sufficiently chemically similar to the quinolones to provoke the development of resistance. If correct, this is very bad news: Malaria is a major killer especially of children, so no one is about to stop prescribing a cheap, effective antimalarial in a highly malarious area. In fact, the WHO and other agencies are preparing a new antimalarial program called ACT (for "artemisin combination therapy"; artemisin is a botanical) that includes a drug family called quinolines that are chemically similar to chloroquine.

Controlling malaria is an important public health goal, but so is controlling antibiotic resistance, especially resistance to effective drugs that poor countries can afford. As one of the authors, Michael Silverman of Oshawa, Ont. warned as the study was releasing:"Chloroquine use for malaria may make the fluoroquinolones less effective for many common tropical diseases such as typhoid fever, diarrheal illnesses, and possibly also tuberculosis and pneumonia in the developing world."

The cite is: Davidson RJ, Davis I, Willey BM, Rizg K, Bolotin S, et al. (2008) Antimalarial Therapy Selection for Quinolone Resistance among Escherichia coli in the Absence of Quinolone Exposure, in Tropical South America. PLoS ONE 3(7): e2727. doi:10.1371/journal.pone.0002727

New entry in the blogroll...

I've added Aetiology, a blog maintained by Tara C. Smith, PhD, assistant professor of epidemiology at University of Iowa and supervisor of the team that found the first evidence of MRSA in US pigs. She's currently running a list of posts on summer science reading. Enjoy.

Of course we would never have thought of that.

A new paper in the Annals of Internal Medicine suggests an astounding technique for figuring out whether patients experienced an adverse event while in the hospital:

Asking them.

No, really.

The study by Massachusetts researchers (from University of Massachusetts, Brown, Harvard, Massachusetts Department of Public Health and Massachusetts Hospital Association) looked back at the experience of more than 2,600 patients in 16 Massachusetts hospitals during 6 months in 2003. The researchers started from the assumption that the medical-records review done by many hospitals to spot adverse events was not capturing enough information — and that the interviews that some hospitals do with patients after discharge were asking the wrong questions because they focus only on satisfaction.

So the team did a 20-minute phone interview 6 to 12 months after discharge for 2,600 patients, asking about "negative effects, complications or injuries," and also reviewed the medical records of 1,000 patients who agreed to their charts' being released for review. For each arm of the study, two physician-reviewers checked results to be sure what was scored as an adverse event actually qualified as one.

And they found: That twice as many adverse events were uncovered when patients were asked about their experience. Among the interviewees, 23 percent reported an adverse event; when records were reviewed, only 11 percent of patients were judged to have experienced one.

Now, let's be clear: I'm very glad these researchers had the courage to do this study. Anything that supports better care, more transparency in care and more responsiveness to the patient's experience is a good thing and I support it.

But when I think of the dozens of hospital patients and family members who have told me about their experiences with poor infection control — lack of hand-washing, lack of housekeeping, bloody gauze on floors — and with being completely unable to get anyone in those hospitals to pay attention, it just makes me want to beat my head against a wall. Coming up with the idea of asking the patients about their experience... this is so hard?

As one of the co-authors, Saul Weingart of Dana-Farber Cancer Institute in Boston, said in an accompanying press release: "It's pretty clear that they can teach us important things about improving patient safety, if only we ask them."

The cite is: Weissman, JS et al. Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? Ann Intern Med 2008; 100-108.

Antibiotic resistance in food animals all across Europe

Via a journal that's new to me — the Acta Veterinaria Scandinavica, the open-access journal of the Veterinary Associations of the Nordic Countries — comes an amazing review of the prevalence of antibiotic resistance in cattle in 13 European countries. Based on 25,241 isolates collected over three years, Denmark, Britain, the Netherlands, Norway, Sweden and Switzerland do well, but "many isolates from Belgium, France, Italy, Latvia and Spain were resistant to most antimicrobials tested."

Most resistant pathogen: E. coli. MRSA is present as well:

Of major concern is the level of resistance to oxacillin and 3rd generation cephalosporins (i.e. ceftiofur) in S. aureus. The prevalence of oxacillin resistance in Spain (3.7%) and France (8.3%) and the resistance towards cephalosporins in Spain (0.9% in 2004) and France (4.2% in 2002; 1% in 2003) indicate the presence of methicillin resistant S. aureus (MRSA) in these two countries.

The authors ascribe the differences among countries to different patterns of antimicrobial use by veterinarians and stress that it is time for veterinarians to begin using measurements of local resistance patterns (in human medicine, an "antibiogram") before prescribing. Cite coming when the Acta site is updated. UPDATE: The paper is here; cite is: Hendriksen, RS et al. Prevalence of antimicrobial resistance among bacterial pathogens isolated from cattle in different European countries: 2002-2004. Acta Veterinaria Scandinavica 2008, 50:28doi:10.1186/1751-0147-50-28.

I wasn't aware that this same set of authors (Hendriksen, RS et al.) just a few weeks ago published a similar review of antimicrobial resistance in pigs in Europe. It looks at several bacterial species in pigs, but unfortunately for our purposes, no S. aureus.

MRSA colonization - the long-term risk

One of the ongoing puzzles of MRSA's behavior is the significance of colonization, that situation of MRSA living on the skin — or in the nostrils or other locations close to the body's external surface — without causing illness. It's not known how frequently MRSA colonization occurs, for one thing: The long-standing estimate of 1% of the population has been challenged by a number of recent studies.

Another persistent question has been whether the risk of illness and death changes as colonization continues. It has been established that up to one-third of newly colonized carriers will become seriously ill within a year of their acquiring the bug (Huang, SS. et al., Society for Healthcare Epidemiology of America Annual Meeting 2006, abstract 157 - not online that I can find)— but what happens beyond that? Does the risk of illness persist or decrease?

In Clinical Infectious Diseases, the same team that defined the risks of recent colonization report that there are significant risks to long-term carriage as well: 27% of invasive illness in the second year and 16% thereafter, based on a review of 281 patients who were followed for at least one and up to four years at Brigham & Women's Hospital, a Harvard Medical School teaching hospital. These patients become very ill, and in addition use a significant amount of health-care resources:

At our hospital, there are 2–3 times as many hospital admissions involving patients previously known to harbor MRSA than there are hospital admissions of individuals who are newly detected as MRSA carriers each year.

What is the precipitating event that tips MRSA carriage over into MRSA illness? It may be health care. In other words, the long-term carriers do not become ill with MRSA disease and then come to the hospital. Instead, they come to the hospital for some other reason, and the surgery, IV placement, dialysis etc. they receive allows their MRSA strain to slip past the protective barrier of their skin and begin an invasive infection.

We submit that these high risks of MRSA infection among culture-positive prevalent carriers are not only preferentially detected because of hospitalization but may, in fact, be incurred because of the device-related, wound-related, and immunologic declines associated with a current illness.

This raises the question of whether any admitted patient found to be colonized should undergo the routine known as decolonization before any other procedures are performed — and whether institutions and insurance companies will be open to the additional hospital days and drug costs that will represent.

The cite is: Datta, R. and Huang, SS. Risk of Infection and Death due to Methicillin-Resistant Staphylococcus aureus in Long-Term Carriers. Clinical Infectious Diseases. 2008 47:176-81.

Isolation: Doesn't work if healthcare workers contaminate themselves afterward

In the new Emerging Infectious Diseases, there is a small but very smart study that ought to get wider play. It was done by a PhD candidate at University of North Carolina, Chapel Hill named Lisa Casanova, with the help of faculty and the local health department.

Background: In certain highly infectious environments — including in-hospital isolation — healthcare workers wear what is usually known as "personal protective equipment" or PPE. PPE generally includes gloves, gown and an eye shield, goggles or face-splash guard (also called "barrier precautions") as well as a mask or a respirator ("respiratory protection"). PPE protects the healthcare worker while he or she is in the patient's presence, but it poses a problem when the worker leaves that environment, because the PPE is likely to be carrying the disease organism on its surface. If the worker doesn't doff the PPE very carefully, he or she might contaminate himself/herself and become infected or colonized, or spread the organism further in the healthcare environment.

This accidental contamination was a significant problem in the 2003 SARS epidemic — so after SARS was over, the Centers for Disease Control and Prevention came up with a recommended procedure for taking off PPE (on this page, half-way down). Casanova decided to test how well the protocol actually works.

Answer: Not so much. She had 10 volunteers (men and women, left- and right-handed) dress in PPE, contaminated the equipment in certain spots ("front shoulder of gown, back shoulder of gown, right side of N95 respirator, upper right front of goggles, and palm of dominant hand") with a benign virus, had the volunteers take off their PPE, and then tested them for the virus's presence. Results:

Transfer of virus to both hands, the initially uncontaminated glove on the nondominant hand, and the scrub shirt and pants worn underneath the PPE was observed in most volunteers.

Casanova recommends changes: additional PPE; different PPE and doffing protocols, such as are used in surgical suites; or PPE impregnated with antimicrobials. (#1 and #3 of course would be more costly; #2 would require procedural change but not necessarily additional garments).

She also raises a vital ongoing issue for MRSA infection control: that healthcare workers may not be punctilious about hand hygiene because they believe that gloves are adequate protection. Only, as this study demonstrates, they are not:

This study also indicates the need for continued emphasis on hand hygiene. A barrier to improving hand hygiene compliance rates is the belief that gloves make hand hygiene unnecessary (14). This is contradicted by our study and others showing that organisms can spread from gloves to hands after glove removal (15). Even if double gloving is incorporated into protocols for PPE use, it is not a substitute for proper hand hygiene.

The cite is: Casanova L, Alfano-Sobsey E, Rutala WA, Weber DJ, Sobsey M. Virus transfer from personal protective equipment to healthcare employees’ skin and clothing. Emerg Infect Dis. 2008 Aug; [Epub ahead of print]