Institutional memory or eternal recurrence?
'We are making a lot of the same mistakes.'
One of infection prevention's true originals — in every sense of the term — Eddie Hedrick, BS, MT(ASCP), CIC, currently is emerging infections coordinator at the Missouri Department of Health and Senior Services in Jefferson City. With decades of experience in infection prevention, he was formerly the manager of infection control and employee health at the University of Missouri Hospital and Clinics in Columbia. A long-term board member of Hospital Infection Control & Prevention, Hedrick recently sat down with us for a Q&A session.
Q. HIC: There is some concern that we may be entering an "age of pandemics," an era of continually emerging infections due to a variety of human and environmental factors.
A. Hedrick: "There are more than 300 diseases that are emerging or re-emerging for a variety of reasons. A lot of them have to do with movement of people, climate change, deforestation, and that kind of thing. I don't think we are going to be consumed by it, but it is something to be prepared for. In the past, we didn't have the opportunities to see things coming. Now we have better surveillance systems and more contact with a variety of different groups so we can keep abreast of this stuff a little better."
Our latest emerging infection is H1N1, the first influenza pandemic in 41 years. How is the response going so far?
"I think there is a tendency to overreact to these kinds of things, and right now the media is saying we are making too big of a deal out of this H1N1. Well, you're damned if you do and damned if you don't. I always tell people, 'Don't worry about it, let me worry about it and I'll let you know when you need to respond.' That's our job, but we're obviously sending mixed signals. We tell people this is a mild disease and then we turn around and start doing all kinds of elaborate things. We're not good at communicating why we are doing some things, but I think people are finally getting it that we have to be flexible. Mother Nature doesn't read all of our guidelines. This stuff doesn't come at us the way we anticipate, so this may turn out to be a Category 1 pandemic when we planned for a Category 5."
Why did you make the transition from hospital infection prevention into public health and emerging infections?
"Well, I think there were a couple of things. They had early retirement at the university, which was very helpful. At the same time, because of my virology background I've always been interested in different organisms. The opportunity came up with emerging infections to be right on the edge of everything new — to be part of a team that addressed disease at the point that it occurred. Public health is where the rubber meets the road. It is different than the hospital orientation; it's more of a community orientation. I was always fascinated by it and had never been involved. This provided that opportunity, so I was retired for all of two weeks."
How did you originally get started in infection prevention?
"I got out of medical technology school back in 1968 and became a clinical virologist. Then in 1970, this whole concept of hospital infection control started to come about at the CDC and they offered some courses. They had [classes on] micro, the hospital environment and some of those things. The field was just getting started. There were only a few of us in the whole country — about 20 of us that were really communicating with one another. I was a bit of an outcast in that I was a male non-nurse.
"There were outbreaks of Enterobacter cloacae and waterborne bugs causing IV-related infections. That sort of began the era of the gram negatives. We saw the resurgence of the gram positives in the late 1970s and 1980s with MRSA and VRE. If you just go back and look at what happened with penicillin-resistant staph in the '50s and '60s, it's the exact same thing that has happened with methicillin resistance. I think now the gram negatives are about to make another stand. This is going to be cyclical because it has a lot to do with antibiotic use and misuse. It's going to come back in another form. One of the speakers at one of the early international infection control conferences pointed out that we were spending all of our time worrying about barrier precautions and very little about antibiotic control. We are doing that all over again."
It sounds like you are suggesting there is some fallacy in the overall approach to infection prevention.
"Well, I think we are making a lot of the same mistakes. One of the problems is institutional memory. So many people in the profession have turned over, retired, and it's like we don't remember what we have been through. To me, a lot of the isolation concepts are just so flawed. It makes people feel good, but does very little. There is not a lot of science driving contact isolation. You can watch the paradigms shift. We went through this whole thing where we switched to body substance precautions, which are now called standard precautions. Then the CDC said that's not enough and we had to add this and add that. Right now we are about to change the paradigm again with this H1N1. If you watch carefully, what the CDC is doing is going from H1N1 to all ILIs [influenza-like illnesses] and emphasizing to the public that they should always be washing their hands, covering coughs, and staying home when they are sick. When you think about it, we're back to standard precautions."
So you favor more of an overall standard precautions approach rather than pathogen-specific or transmission-driven isolation precautions?
"Bug-specific precautions really don't make a lot of sense to me. You can't tell what somebody has. You have to wait until it comes back from a laboratory, which is usually several days later. Even if I screen the world for everything, something else will pop up. Nature abhors a vacuum. We are going from bug to bug to bug, and pretty soon you have everybody in the hospital in isolation. I have a T-shirt from 1975 that a bunch of us made at one of the conferences that says: 'Bugs do it every 20 minutes.'
"They are going to overwhelm you because they reproduce so fast and they adapt to everything we throw at them. The key is to be consistent. What I have always taught in my practice is consistency. Don't wait for [the infection preventionist] to tell you about some [pathogen]. Eliminate the 'uh-oh factor.' When I used to walk in and say, 'Mr. Jones has this disease' — and everybody in the room goes 'uh-oh' — I knew they hadn't been practicing the way they should have. Nowadays, we want zero risk and we want to put everybody in a total body condom. We need to challenge all of the rituals out there and figure out what works, what doesn't, and why."
What about the movement toward zero tolerance of infections?
"All of this talk about going to zero infections — I understand that is a goal, but there are people out there telling patients you can actually attain that. That just scares the hell out of me. It's partly an illusion — these articles that show if you culture people for MRSA and then put them in isolation that it will completely lower the MRSA infection rate. The fact of the matter is all we are doing is changing the definitions. If you culture people — and they happen to be a carrier when they came into the hospital — when they get infected two weeks later, then it is no longer nosocomial. That becomes a community-acquired infection. Yes, but the incision [from an invasive procedure] wasn't there when they came in. How did the MRSA get from that person's nose into the wound? What did we do?"
One of infection prevention's true originals â in every sense of the term â Eddie Hedrick, BS, MT(ASCP), CIC, currently is emerging infections coordinator at the Missouri Department of Health and Senior Services in Jefferson City.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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