Thursday, October 20, 2016

The Human Microbiome, Koch's Postulates, Infection Prevention

This week our own Dr. Wenzel presented an update on the dynamic human microbiome, exploring the interaction of bacterial diversity, homeostasis and infection prevention. Masterful.  He will be giving this lecture at the 2016 ID Week conference in New Orleans, next week.

For hospital infection prevention, much of the current thought is on both preserving the current microbiome and restoration of bacterial normalcy in select situations (fecal microbiota transplants), as summarized in this scholarly review.

Our knowledge of the human microbiome is rapidly expanding, as witnessed by the number of publication cited over the last several years in PubMed (over 5,500 articless last year alone vs. 245 in 2005).

Our understanding of bacteria, disease and wellness is evolving such that Koch's Postulates are not so neatly applicable anymore. Some bacteria are important components of the normal microbiota, preserving homeostasis, yet pathogenic at other times (Staphylococcal species on the nose and skin, fermicutes, bacteriodetes and Clostiridium in the gut).

As we bathe patients with chlorhexidine and decolonize with mupirocin, decreasing the burden of potentially dangerous pathogens to prevent hospital acquired infection, we alter the normal microbiome, possibly disrupting our protective microbial balance. 

We are in a constant evolution with the microbes and we have much to learn.

Monday, October 17, 2016

C. difficile Reduction in the Hospital- It's the Environment!

Like many hospitals we have struggled to control the rise of hospital acquired C. difficile infections. 

We have finally turned the corner and have decreased the rate of infection with a broad platform that includes enhanced hand hygiene (soap and water), early detection and isolation of patients, heightened bleach daily and terminal room disinfection (with audits and feedback) and the aggressive deployment of UV-C light robots (again, with audits and feedback) for the terminal cleaning of rooms previously inhabited by a C.difficile patient. The focus is on isolation and bioburden (spore) reduction. 

As with many similar multi-pronged strategies, the proportionate impact of each component is hard to measure.

Note this important paper, recently published, that underscores the importance and impact (25% reduction) on C.difficile incidence of strategically deploying a UV-C irradiating robot for terminal room disinfection.

The environment is an important driver of hospital acquired C.difficile infections. 

Tuesday, October 11, 2016

Why Physicians in Healthcare Leadership Should Talk the Talk and Walk the Walk

I firmly believe that physicians in healthcare leadership should continue to see patients, and so do the authors of this recent opinion article in the Annals of Internal Medicine.       

The reasons are multiple. Being truly informed about the 'state of things' on the ground is critical. Front line healthcare workers have a perspective and awareness that simply cannot be learned any other way. To understand how a medical organization functions one needs to be present, seeing patients in the clinic or in the hospital. Relying on 'memory' from prior clinical practice does not work, much like expecting a fine athletic performance while no longer engaging in physical training.

Clinical credibility is also huge and can only be obtained through direct patient care. Last, seeing patients is personally fulfilling. Isn't that why we went into medicine after all? Now, all this takes effort and makes for long days but few worthwhile things come easy.

Physician leaders in healthcare should talk the talk and walk the walk

Wednesday, October 5, 2016

On Bullshit

This is not a new publication, simply new to me: On Bullshit, by Princeton UniversityProfessor Harry Frankfurt. The full text is available here.

Do not let the jocular nature of the title fool you, this is a serious short book (essay, really) written in 1985. 

Bullshitting is not lying, which is a willful act and implies a knowledge of the truth. A bullshitter doesn't care about the truth. He is engaged in the enterprise of manipulating and selling an opinion. Bullshit is likely more pervasive than lying and certainly more insidious.

For an entertaining and informative interview of Professor Frankfurt on the Daily Show, click here.

On Bullshit should be required reading during election time.

Friday, September 30, 2016

Sometimes the Messenger is as Critical as the Message

The other day I attended a lecture by a highly respected nurse-PhD investigator. The lecture explored the critical impact of nursing on safety and patient centered outcomes. The presentation was backed by robust data and highly relevant references.

The crowd was unmoved (some were bored and walked out), which is a true shame.

I have always felt that an engaged and effective lecturer uses narrative, enthusiasm and passion to move the audience. The messenger can be as important as the message, as summarized in this post.

Opportunity lost for being a change agent.

Wednesday, September 28, 2016

Automated Teller Machines and Pedestrian Crossing Controls - Not the Next Epicenter for Gram Negative Rods!

Really? Someone actually tested the microbial burden on automated teller machines (ATMs) and pedestrian crossing controls?

The answer is yes and no gram negative rods, including ESBL and CRE organisms were identified. Only gram positive organisms were found as reported in this brief  article published in the Journal of Hospital Infection

I understand that ATMs and and pedestrian crosswalk buttons are high touch surfaces, but need we be so germaphobic? Microbes are ubiquitous. What shall we culture (or re-culture) next? All door handles, steering wheels, and poles on subway cars? We already know that cellphones carry a significant bioburden, as summarized here.

I would simply suggest that we practice hand hygiene prior to eating and that we limit touching our eyes, nose and mouth, to the fullest extent possible, with unwashed hands.

Germaphobe I am not!

Thursday, September 22, 2016

The Mask of the Red Death, Cholera and a Good Read on Infectious Diseases

It was just the other day that I learned that the short story, The Mask of the Red Death, written by Edgar Allen Poe, was inspired by the events of a society ball held by German poet Heinrich Heine. The ball was held in the midst of the 1832 Paris cholera epidemic which claimed 19,000 lives in total. During the ball, a harlequin dancer felt a chill in his legs and took off his mask, revealing a violaceous face. The chlolera symptoms had begun. By the end of the night, several party goers, along with the harlequin, were dispatched to the famed Hotel-Dieu where they later died of cholera.

For infectious diseases nerds, such as myself, here is a good read titled Pandemic by Sonia Shah. The author explores the emergence of new pathogens and pandemics, including cholera, in both a scholarly and gripping fashion.

Outbreaks do not occur randomly, rather, they are the consequences of expanding urbanization, deforestation, crowding, poor public health infrastructure, misuse of antibiotics and globalized, highly connected travel.

Good read.