Yogurt and C.difficile Infections in the Hospital

Here is an intriguing report in The Hospitalist on encouraging the consumption of yogurt by hospitalized patients receiving antibiotics. The health system performing this intervention reported a significant decrease in the rate of C.difficile associate diarrhea.

I have multiple reasons to be skeptical. First, I cannot find this report cited in any peer reviewed, medical journal. How can one be sure that introduction of a 'yogurt diet' was causally related to a change in C.difficile rates? What about other important factors such as changes in antibiotic stewardship, hand hygiene practices, length of stay, changes in room disinfection? Too many unanswered variables and the study design was not rigorous.

Also, the largest, most recent probiotic trial failed to show benefit on preventing C.difficile associate diarrhea. 

Yogurt will likely not impact  C.difficile in acute care settings.

The Rushed Doctor

I am a bit off topic as this is not related to infectious diseases.

Here is a telling editorial published in the New York Times on the rushed doctor. The bottom line, in attempt to accommodate the growing numbers of patients, encounter times are decreasing. This may not be the best for patient safety, satisfaction and outcomes.

In my institution, we have yet to feel the time pinch as acutely. We still are allowed 30 minutes for a follow up visit and 60 minutes for new patient. Owing to overbooking of cases, admittedly self imposed to accommodate the clinical demand, time pressure does become a factor

Another recent editorial refers to the bottleneck in training doctors.

Challenging.

Hand Hygiene and Video Observation in the Operating Room

In my institution, we are launching into an initiative for enhancing hand hygiene (HH) in the OR. Although the surgical hand scrub is an inviolate ritual in the surgical arena, hand hygiene in and around the OR is much less robust. The body of literature on HH in the OR is much smaller than in non-OR settings.  Here is an article on the use of video observation for HH monitoring that was recently published in the the American Journal of Infection Control.

The investigators used video observation in the OR to map patterns of anesthesia provider hand contact with anesthesia work environment (AWE) surfaces and to assess HH compliance. The World Health Organization criteria for HH was used as the HH standard. Serial bacterial cultures of high contact objects were performed to characterize bacterial transmission over time.

A low rate of HH compliance by anesthesia providers was observed (mean, 2.9%). Most importantly - an inverse correlation was observed between provider hand hygiene compliance during induction and emergence from anesthesia (3.2% and 4.1%, respectively) and the magnitude of AWE surface contamination (103 and 147 CFU, respectively). 

We need better mechanisms to both encourage HH and to make it feasible in an OR, particularly at the anesthesia work station. This will require education, promotion and feedback.

The benefits of improving HH in the OR is based on biological plausibility. The real impact of HH on surgical site infection remains unknown. This knowledge gap poses a problem for implementation and ''buy in'' from healthcare workers.

An uphill climb looms.

VCU MIDPH 2014- Congratulations to VCU Medical Students Sarah Hughes and Tammy Tran

Congratulations to VCU Medical Students Sarah Hughes and Tammy Tran, who presented their Microbiology, Infectious Diseases and Public Health Program (VCU MIDPH) summer research on July 7, 2014.

Sarah's work focused on infection prevention strategies in the medical ICU and Tammy studied Lyme disease ecology and climate patterns.

Kudos to both.

Asymptomatic Bacteriuria and Prosthetic Joint infection- Less is More

I am back on the ID consult service today. This will certainly keep me busy and conflict with viewing the World Cup games. 

Here is an intriguing article in Clinical Infectious Diseases that caught my eye this weekend.This was a multicenter study of patients undergoing total hip or total knee arthroplasty. A urine sample was cultured in all patients, and those with asymptomatic bacteriuria were identified. A total of 2497 patients were enrolled. The prevalence of asymptomatic bacteriuria was 12.1% (303 of 2497), 16.3% in women and 5.0% in men (odds ratio, 3.67; 95% confidence interval, 2.65-5.09; P < .001). The overall prosthetic joint infection rate was 1.7%. The infection rate was significantly higher in the asymptomatic bacteriuria group than in the non-asymptomatic bacteriuria group (4.3% vs 1.4%; odds ratio, 3.23; 95% confidence interval, 1.67-6.27; P = .001). 

But here is the most intriguing finding: in the asymptomatic bacteriuria group, there was no significant difference in joint infection rate between treated (3.9%) and untreated (4.7%) patients. Also, prosthetic joint infections did not correlate to isolates from urine cultures!

To me this underscores, again, that asymptomatic bacteriuria should not be treated except in pregnancy and in patients about to undergo invasive bladder procedures. Treatment of asymptomatic bacteriuria does not impact outcomes and likely breeds antibacterial resistance. 

With respect to treating asymptomatic bacteriuria, less is more.

The Staphoscope- A Potential Vector for Healthcare Associated Infections

I have previously blogged about our dirty stethoscopes (staphoscopes) and about possible disinfection strategies at the point of care. 

Here is a recent entry from the National Patient Safety Foundation Blog on 'Foaming in and Foaming Out,' both in the context of hand hygiene and stethoscope disinfection. 

An ongoing challenge for infection prevention professionals is accurately estimating the degree to which an instrument such as a stethoscope is responsible for hospital acquired infections. This would support the argument of decontaminating stethoscopes and any other material which comes into direct contact with patients in the clinical environment.

Much like hand hygiene, the disinfection of stethoscopes will require a behavioral change, aided by education, ubiquitous access to disinfection wipes, observation, feedback and accountability. 

To date, there is no prospective study assessing the impact of stethoscope disinfection on the rate of hospital acquired infections so making a convincing argument in favor of a behavior change is based on commonsense and biological plausibility. 

Changing behavior is much easier said than done.

World Cup Time- Why So Many Soccer Fans Dislike Argentina

I have taken a break from blogging as of late, the reasons are multiple. The most immediate reason is that the World Cup has diverted my attention.

Being both a soccer player, albeit over the hill, and an Argentine, the title of this article in the NY Times was eye catching.

I certainly hope that we win the World Cup. Being boastful and arrogant never gets you too far.

In sport or otherwise, it is helpful to remember the following: 
All Glory is Fleeting- General George C. Patton