Friday, January 30, 2015

Rethinking the Efforts of the Hospital Infection Prevention Program

Here is a recent message from APIC that caught my eye. It is a call to action of sorts.

We are in pressing times in infection prevention. More than ever, we are expected to implement and drive infection prevention efforts at our hospitals. The public expects preparedness for emerging and re-emerging diseases such as MERS and Ebola. For many infection prevention programs, the demands increase without a commensurate increase in resources and personnel.

As previously mentioned in a prior posting, accessible here, we need better methods for adequately calculating the staff and resource needs of a modern, hospital based infection prevention program.

Monday, January 26, 2015

Bacteremic Sepsis in Transplant vs Non-Transplant Patients- Paradigm Challenge

The conventional thought is that sepsis and bacteremia is more severe and life threatening in transplant recipient patients. The immunocompromised state of the transplant recipient theoretically heightens the severity of illness and increases the risk of a poor outcome.

This recent paper in Clinical Infectious Diseases suggests otherwise. The investigators reported a 78% relative decrease in 28 day mortality between bacteremic sepsis in transplant recipients versus non-transplant recipients.

Although transplant recipients may be immunosuppressed and at risk for opportunistic infections, particularly from viruses and fungi, in the event of bacteremic sepsis they fare better than non-transplanted hosts.Why? It is quite likely that the immunocompromised state down regulates the inflammatory response of sepsis, improving survival.

Once again, empiric data and observation contradict intuition.

Wednesday, January 14, 2015

Antibiotics Therapy Optimization- Room for Improvement

It is a common opinion that antibiotics are misused in US hospitals. The fears of evolving antibiotic resistance continue to grow.

When empiric antibiotics are prescribed on hospitalized patients, how appropriately are they prescribed and how quickly are they streamlined or discontinued? Here is an article published in Lancet Infectious Diseases which raises concerns in my opinion.

Across 6 US hospitals ( 2 university hospitals, a public community hospital and 3 private community hospitals) over a course of one year, of the 1200 selected patients on antibiotics, 30% had no fever and normal WBC counts, appropriate cultures were obtained on 59% of patients and, after 5 days of therapy, 66 % of patients had no change in their antibiotic therapy. 

Antibiotics are overused, particularly ones with a broad therapeutic spectrum, frequently on patients with no clinical signs of infection or fever. Concerning.

We only have ourselves to blame for the ongoing rise in drug resistance and C.difficile infections.

Monday, January 12, 2015

Rethinking the Prevention of Ventilator Associated Pneumonia

Ventilator associated pneumonia (VAP) is the least common yet the most dangerous of hospital acquired, device associated infections.

Selective digestive decontamination (SDD) works for the prevention of VAP. Many infectious diseases, including myself, have an aversion to prescribing antibiotics for preventive measures, largely owing to the fear of selecting antibiotic resistant organisms. For many, this is dogma. 

This recent paper, a systematic review and meta-analysis published in Clinical Infectious Diseases, summarizes much of the data in VAP prevention and challenges our hang ups. Current data suggests that SDD is one of the most effective measures to prevent VAP and reduce mortality.

We must rethink our objections to SDD for VAP prevention and push ourselves to study both the short and long term benefits of digestive decontamination. 

Interventions should be guided by data. Data trumps dogma. 

Thursday, January 8, 2015

Patient Care, Interruptions and Breaks in Task- A Day in the LIfe

I spent much of the last 2 weeks covering the ID services in the hospital. The pace was fast and the patient load was heavy. These last few weeks had me reflecting on how my time is actually spent in the hospital and how often I am distracted by phone calls, pages etc.

I dug up this article, on how hospitalists spend their time. Much of it is on indirect patient care activities, such as charting and making phone calls, coordinating care. Per this publication, only 18% of the time in the hospital is spent on actual patient care. I believe it.

Next, I found this article on interruptions and breaks-in- task in an emergency department. An "interruption" was defined as event that briefly required the attention of the doctor but did not result in switching to a new task. A "break-in-task" was defined as an event that resulted in changing tasks. Not surprisingly, per each 180-minute review period, there were on average 40 interruptions and 21 breaks-in-task. Are airline pilots distracted as often when flying a plane?

We are driven to distraction and this certainly cannot be good for either efficiency or patient outcomes. The challenge lies in quantifying the impact of distractions on patient safety, and, in response, designing systems where patient care is both the primary focus and is insulated from unnecessary distractions. This would be huge. 

Monday, December 29, 2014

Fever- The Story of Typhoid Mary

For those of you looking for a good medical read, I would suggest Fever, by Mary Beth Keane. This medical novel focuses on the life of Mary Mallon, infamously known as Typhoid Mary.

The narrative goes beyond depicting the medicine and evolving understanding of infectious diseases at the turn of the 19th century. At its core is a deep and meaningful story about love and survival. 

Despite the sickness and death inflicted by a Marry Mallon, one cannot help but sympathize with her struggle and see her as a sadly forgotten heroine of an era long past.

Well worth reading.

Tuesday, December 16, 2014

University of Nebraska Biocontainment Unit Visit















I have spent the last few days at the University of Nebraska at the Ebola Training Course. This was an excellent experience and will definitely improve the finalization of the VCU Unique Pathogens unit, which is imminent.

Back to Richmond tonight and back to ID consults tomorrow.