Friday, April 29, 2016

Antibiotic-Associated Encephalopathy- Beware

In my opinion, antibiotics are overused largely because they are effective and generally safe. However, adverse consequences occur and include more than just rashes, nausea, diarrhea and renal insufficiency. Here is an excellent review on antibiotic-associated encephalopathy published in the American Academy of Neurology.


Delirium is common in hospitalized patients yet antibiotics, although overused, are under recognized as a cause of confusion.    

The authors report 3 unique clinical antibiotic associated encephaloptahy syndromes: encephalopathy commonly accompanied by seizures or myoclonus arising within days after antibiotic administration (cephalosporins and penicillin);encephalopathy characterized by psychosis arising within days of antibiotic administration (quinolones, macrolides, and procaine penicillin); and encephalopathy accompanied by cerebellar signs and MRI abnormalities emerging weeks after initiation of antibiotics (metronidazole). 

Perscriber beware, antibiotics are not harmless and the side effects can include the precipitation of acute confusional states.

Saturday, April 23, 2016

Social Spending and Tuberculosis Burden: A Global Perspective

The last week was a bit punishing for me on the infectious diseases consult service. The Gods of Infectious Diseases must have been displeased with me.

Finally back to the blogosphere and finally a paper in a scientific journal that addresses tuberculosis as a social issue and not merely a medical one.

Here is an article published in the Lancet Infectious Diseases on the association between spending on social programs (in % GDP) and the burden of tuberculosis.


Overall, social protection spending levels were inversely associated with tuberculosis prevalence, incidence, and mortality. For a country spending 0% of their GDP on social protection, moving to spending 1% of their GDP was associated with a change of -18·33 per 100 000 people in prevalence, -8·16 per 100 000 people (-16·00 to -0·27; p=0·043) in incidence of TB. Decreased morality was also observed. This lost significance when more than 11% of GDP was spent.

Epidemiology 101: Correlations do not prove cause and effect, but they do generate valuable hypotheses. In this example, it is well known that TB (and other illnesses) are a function of poverty, crowding, sanitation and malnutrition. Social spending alleviates these negative health pressures. There is plausibility in the argument that social spending may impact certain health outcomes.

Poverty has negative health consequences. That much is irrefutable.

Friday, April 15, 2016

Antimicrobial TV Remote Controls and Hotel Rooms: Public Health Hazard?

I was recently staying in a posh New  York City hotel and noticed the 'antimicrobial' TV remote control. Intrigued, I did a bit of research. I found this article on antimicrobial television remote controls in the Daily Mail from the UK.

On a more academic level, a recent scientific publication in the Journal of Environmental Health highlights the potential microbial 'threat' of hotel room items. Coliforms (fecal bacteria) were recovered from 36% of surfaces with high prevalence being recovered from the comforter, TV remote, bathroom countertop, faucet, and toilet seat. Oxacillin-resistant bacteria were recovered from 19% of surfaces with 46% of isolates confirmed as MRSA.


Has one ever heard of a point source outbreak from a TV remote control? Microbes are ubiquitous and antimicrobial TV remotes are a gimmick. We do not live in a germ-free world so fear not the TV remote control.

In my professional opinion, the public health impact of antimicrobial TV remote controls is nil.

Thursday, April 7, 2016

Fresh or Frozen, Does it Matter? Fecal Transplantation for the management of Recurrent C. difficile Infection

A major barrier to Fecal Microbiota Transplantation (FMT ) for the management of recurrentC. difficile infection is obtainment of the donor stool. 

Enter Open Biome, a non-profit organization that provides hospitals with screened, banked frozen stool for administration.

I regularly  perform FMTs at VCU Medical Center by infusing banked donor stool from OpenBiome into the duodenum via a dobhoff tube. This protocol was pioneered at our center by Dr. Micheal Edmond, now at the University of Iowa. The efficacy of FMT via duodenal infusion is supported by this important article in the New England Journal of Medicine.

This article, recently published in the Journal of the American Medical Association, suggests that banked, frozen stool is at least as effective as a fresh stool for the management of recurrent C. difficile. Banking frozen stool in the pharmacy for use on demand is a massive simplification and improvement over patient identified donor stool.  In my opinion,the procedure has become more simple than ever.

The FMT reimbursement is minuscule, but in the end, that's not what to motivates us to help others.

Saturday, April 2, 2016

Choosing Wisely- Antibiotic Treatment in the Hospital

It seems like I am on the theme of antibiotic stewardship of late. Here is the link to Choosing Wisely, specifically on antibiotic treatment in the hospital. This report is a collaboration between the Society for Healthcare Epidemiology of America (SHEA) and Consumer Reports.

The message is simple:

Don’t continue antibiotics beyond 72 hours in hospitalized patients unless patient has clear evidence of infection.


Antibiotics are often started when a patient is possibly infected. After three days, laboratory and radiology information is available and antibiotics should either be deescalated to a narrow-spectrum antibiotic based on culture results or discontinued if evidence of infection is no longer present. 

Lessening antibiotic use decreases risk of infections with Clostridium difficile (C. difficile) or antibiotic-resistant bacteria.

Any questions?

Tuesday, March 29, 2016

Curtailing Unnecessary antibiotic Use and the Peer to Peer Comparison

It is estimated that nearly 50% of all outpatient antibiotics are unnecessarily prescribed. This recent article in the Sunday New York Times Sunday Review explores mechanisms in which antibiotic prescription can be curtailed. One study highlighted in the article employed a peer-to-peer comparison of antibiotic prescribing practices across primary care providers.

When compared to peers, physicians categorized as 'poor performers' tend to improve their practice, in this case with respect to antibiotic prescribing.

I have learned that the peer-to-peer comparison is a powerful tool for driving behavior change an improving best practices in infection prevention. Surgeon-to-surgeon comparison of surgical site infection outcomes heightens attention to risk reduction interventions. Comparisons between units and wards are also powerful, particularly when it comes to adherence with best practices such as hand hygiene, head of bed elevation, chlorhexidine bathing, central line insertion checklist completion and daily review with documentation of ongoing urinary catheter need.

Physicians and nurses, particularly those in leadership, tend to be high achievers. Use it as an advantage. No one provider or hospital unit wants to be the outlier in poor performance.

Thursday, March 24, 2016

American College of Physicians (ACP) Interveiw

Several months back I did an interview for the American College of Physicians. The interview was geared toward medical students and was published online recently. 

I am certain that the content is not the least inspirational, nevertheless, I am am honored that the ACP reached out to me.