On the Argentine: Random Images from Buenos Aires

I am now back in my native Córdoba, Argentina, by way of a one day pit stop in Buenos Aires. 

Below are a few random images from Buenos Aires, including the Recoleta Cemetery and El Gran Ateneo book store, know as one of the best bookstores in the world, as highlighted in the Guardian UK. I picked up some choice new books.

Also, La Biela confiteria, former meeting place of argentine writers such as Jorge Luis Borges and Adolfo Bioy-Casares.

Un día perfecto.

The VRE Train! Gowns and Gloves Not Required

VRE Train! Gowns and gloves not required

Hashing it Out! Program Planning.

I visited SHEA headquarters in Arlington, VA earlier this week, where I had the honor of participating in the 2018 SHEA Spring Annual Meeting planning committee. 

Really looking forward to the event, some exciting and controversial topics made the final program cut.

At the Amtrak station on the way back home to Richmond, I nearly (and aptly) hopped on the VRE Train (Virginia Railway Express), where gowns and gloves are not required, just how I like it.

When Having An Infectious Disease Was Fashionable And Socially Acceptable

While perusing the latest issue of the Lancet Infectious Disease I learned of an event titled Fashionable Diseases, which took place at the Edinburgh International Science Festival (April 2017). A Scottish news article on the event can be found here.

Yes, there was a time when having syphilis and even tuberculosis was trendy and even socially acceptable.Gout was seen as glorious, a reflection of affluence. Still, double standards abounded. Syphilis in men was a marker of sexual prowess. In women, sexually transmitted diseases were associated with prostitution and low morals. 

Although modern times are different (we now understand disease transmission and have treatments), some infectious diseases are still viewed through a societal lens. Lyme disease (Borrelia burgdorferi) and Syphilis (Treponema palladium) are both spirochetal diseases. Both have various phases of infection: early infection then later manifestations. Both are fully treatable with antibiotics.  Lyme disease is more commonly seen in Caucasian, upper middle class populations with tick exposures. Lyme advocacy groups are well rooted in the USA. The same cannot be said for syphilis, which is definitely not a socially acceptable spirochetal disease.

Although not seen as fashionable anymore, infectious diseases still evoke varied sympathies.

Something Has Been Changed In My Life: The Talking Heads, MALDI-TOF and Central Line Bloodstream Infections

David Byrne of the Talking Heads: Give Me Back My Name

I have been radio silent the last several days. The VCU ID consult service has been high volume!     

I am proud to have published this concise article with colleagues from Philadelphia and Dr. Chris Doern of Virginia Commonwealth University, my home institution. Bottom line, our report explores the potential impact that mass spectrometry (MALDI-TOF) can have on CDC defined central-line associated bloodstream infections (CLABSI). With MALDI-TOF, previously classified skin commensals can now be identified as pathogens thus meeting the CDC criteria for a reportable CLABSI.

What is the scope of the problem? Unknown thus far. With increased use of MALDI-TOF, the issue may be burgeoning. The CDC may need to reassess the CLABSI definition and its surveillance associated master organism list.

Thanks to Dr. Dan Diekema for a cool blog post on the article, with an associated Talking Heads song (Give me back my name, something has been changed in my life - lyrics here). 

One my favorite bands.  I have the LP spinning on my turntable as I type this blog post.

She Blinded Me With Science! Creativity, Non-Conformity and Moving Ideas Forward

Although not my favorite musical artist, I do respect the vision and creativity of Thomas Dolby (of She Blinded Me With Science songwriting fame). His perspective on stimulating creativity can be seen below in this short TED video.

To quote Mr. Dolby, to really be creative " throw away that crutch and work outside of your comfort zone." Try something new, feel the buzz of excitement.

This reminded me of a book that I recently read, Originals, by Adam Grant, wherein he explores how non-conformists move the world. The TED talk by Adam Grant can be found here. I particularly like the concept of being a tempered radical, toning down an idea so as to allow it to take root and flourish. This is a form of pragmatism, something I fancy. In our experience, without an element of tempered radicalism and pragmatism we would never have convinced our hospital administration to discontinue the use of contact precautions for MRSA and VRE. Other concepts highlighted in Originals include questioning the default, exploring multiple ideas while accepting that most will fail, obtaining critical feedback and even procrastinating strategically (so as to let things simmer and mature).

These principles are universally applicable, even in a seemingly less creative field as infectious diseases. Ideas and strategies are the drivers of improved health and outcomes. To that I say challenge existing paradigms if the evidence supporting them is weak. Try new things yet do no harm.  Ask why or why not? Many ideas may not pay dividends in the end. If so, no worries, move on to something else.

Most importantly, surround yourself with talented people and encourage them to explore new perspectives and strategies. In the end the output of the team will exceed the sum of the individual parts. 

Reflections on Gowns, Gloves and the Endemic Threshold

I apologize for a longer than usual blog post today.

I have been giving some thought to comments relevant to my work posted on the HAI Controversies Blog. First, I would like to say that the comments are welcomed and drive discussion and debate. I love it.

With respect to the BUGG study and universal gloving, I am not dismissive of personal protective equipment (PPE). As posted in the comment section by one reader, the way that PPE is used probably is important. In this vein, we feel that healthcare workers should be trained for competency in the use of gowns and gloves, as published here. However, we struggle to take make the training effective to scale- across 7000+ healthcare workers in our institution. This would have to be done in a sustained fashion, particularly as employment status changes across personnel. No easy task.

I am frequently asked about a threshold for instituting or discontinuing contact precautions for endemic pathogens such as VRE and MRSA. This is explored in a recent blog post by Dr. Perencevich. I have no endemic threshold (infection or colonization pressure) in mind. Before making a change in infection prevention strategy it is important to understand your institutional trend in all device associated infections, surgical site infections and MRSA and VRE infections.  One must also have confidence in the reliability, as judged by aggressive, standardized audit and feedback, of a horizontal infection prevention platform. With consistently decreasing device associated infections/surgical site infections (CDC definition), decreasing MRSA and VRE infections and a reliable, horizontal infection prevention platform, we discontinued contact precautions for MRSA and VRE in our institution in 2013. The infection rates continue to decline and we have observed no increase in patient harm. We are not alone in this approach, as summarized here.

I realize that the above may not satisfy the calls for high level methodology, however, cluster randomized trials to answer the above 'endemic threshold' question for contact precautions may never materialize. 

Should new data contradict our experience or should infection rates increase, regardless of pathogen, it would be time to critically reassess all elements of our infection prevention program. Everything would then be back on the table.

If I am labelled as biased then that bias is pragmatism.

Antibiotic Overuse: A Tragedy of the Commons and the Challenge of Physician Autonomy

Source:Medscape

Antibiotic overuse is tragedy of the commons, whereby over-prescribing a shared good, antibiotics, reduces therapeutic efficacy as a result of antibiotic resistance. 

Silverman and colleagues recently reported that 46% of patients from an ambulatory cohort were prescribed broad spectrum antibiotics for acute, upper respiratory infections, which are almost always viral in etiology. Mid - or late-career physicians, physicians with high patient volume and practitioners trained outside of the USA or Canada were more likely to write a prescription for an upper respiratory infection.

Outpatient antimicrobial stewardship programs along with financial incentives and peer-comparison approaches may curb excessive antibiotic prescribing. This likely works best for physicians practicing under the umbrella of a healthcare system or a university hospital where there is oversight by antimicrobial stewardship programs. What about the rest of them?

Approximately 33% of US physicians work independently. The website of my state's medical society explicitly states that "No one knows the medical needs of your patients better than you." 

Physician autonomy and independence are powerful forces in the USA. Curbing unnecessary antibiotics and imposing antimicrobial stewardship programs against this tide is no small task.