Friday, April 29, 2011

Foodborne Pathogens of Public Health Significance

I came across this cool WSJ healthblog as I was skimming my GoogleReader.

Source: WSJ
It is well known that foodborne illnesses can cause significant morbidity and mortality. A new report from the University of Florida's Emerging Pathogens Institute, summarized and linked from the WSJ article, details the 10 deadliest pathogen-food combinations.

  1. Campylobacter in poultry: $1.3 billion annually, 9,500 lost quality adjusted life years (QALYs)
  2. Toxoplasma in pork: $1.2 billion, 4,500 QALYs
  3. Listeria in deli meats: $1.1 billion, 4,000 QALYs
  4. Salmonella in poultry: $700 million, 3,600 QALYs
  5. Listeria in dairy products: $700 million, 2,600 QALYs
  6. Salmonella in complex foods: $600 million, 3,200 QALYs
  7. Norovirus in complex foods: $900 million, 2,300 QALYs
  8. Salmonella in produce: $500 million, 2,800 QALYs
  9. Toxoplasma in beef: $700 million, 2,500 QALYs
  10. Salmonella in eggs: $400 million, 1,900 QALYs
Carnivores are not exclusively at risk, even vegetarians can get Salmonella from produce.


Thursday, April 28, 2011

Hand Hygiene in the Modern Era

Safe Care: It is still all about clean hands
For a cool perspective on hand hygiene and novel technologies to improve compliance, check out this blog post by Dr. Michael Edmond and associated New York Times commentary.

That is all for today.

Wednesday, April 27, 2011

Inappropriate Vascular Devices- Not Without Harm

What impact does inappropriate catheter use have on the risk of adverse events and bloodstream infections? A recent paper in Journal of Hospital Infection aims to answer that question. 

Using a prospective observational study design, the investigators developed definitions for appropriate intravascular device use, estimated the frequency of inappropriate use of intravascular devices, and examined risk factors and outcomes associated with inappropriate intravascular catheter use. Among 436 patients studied, the use of 876 intravascular devices (both peripgeral and central) was observed. Thirty one percent of all catheter days were found to be inappropriate. 

Using logistic regression analysis,  inappropriate usage was strongly associated with increased intensive care unit admission (OR 5.98 P < 0.05) and length of hospital stay (4.9 ± 4.3 days for appropriate vs 8.5 ± 12.6 days for inappropriate; P < 0.05). 

Inappropriate device use was not significantly associated with collection of blood and catheter tip culture, presumably a surrogate marker for a bloodstream infection. Larger studies are needed to assess the impact, if any, of inappropriate intravascular device use and risk of bloodstream infection.
Perhaps our coveted central line checklists should have an initial 1st step: certify the need and appropriateness of intravascular catheterization prior to insertion.

Tuesday, April 26, 2011

Internal Medicine vs. Primary Care

I have blogged before on matters of medical education. As I am both an internist and an infectious diseases specialist, as well as a medical educator, I found this WSJ Blog and original Archives of Internal Medicine publication relevant.

Source: WSJ
In brief, we have a projected physician shortage. We need more primary care doctors to manage the health and prevention needs of an aging population. Many primary care doctors are internists but not all internists are primary care doctors (as many choose hospital based practices or subspecialties). Many medicals students have positive perceptions of internal medicine but not primary care.

With growing medical education debt, long hours, high stress and lower reimbursements (than that of procedure based specialists, dermatologists etc), it is difficult to attract students to primary care.  The shortage of primary care physicians has no apparent end.

Other than coercion, which, I do not favor, meaningful incentives must be made available to lure medical graduates into primary care.  Otherwise, who will take care of me when I am old?

Monday, April 25, 2011

Cosmetic Surgery, The Chinese Way

I am off the topic of infectious diseases and treading out of my comfort zone.

Source: NY Times
Back in 1997, in the last semester of medical school, I spent 4 weeks in Beijing, China, as a visiting medical student at the Capital University of Medical Sciences. Part of the personal allure was the opportunity to experience medicine in the Eastern tradition. My hosts, however, were more interested in showing me their sophisticated medical services, ICUs, CT and MRI scanners. 

They were modernizing, quickly. The Beijing skyline was densely populated with tall buildings and ubiquitous, construction cranes, testaments to the breakneck growth of a country on the rise.

With a capitalist economy and wealth comes the growing need for newer, non-traditional medical services. Cosmetic surgery.

This recent NY Times article explores the growing demand for cosmetic surgery in China, a trend incentivized by high reimbursement,  little medical regulation and supported by a young, vain and wealthy clientele.  

Modernity is now in Chinese medicine. This is a massive departure from the barefoot doctors of China's recent past.

Friday, April 22, 2011

Patients as Consumers

I will be brief.

Medicine is not a simple commodity to be bought and sold on a market. Patients are not simply 'consumers' or 'clients'. 

People often go to the doctor during times of acute illness, emergency and discomfort, thus the notion of 'price shopping' for a physician, much like one would do for a television of automobile, is off the mark.

People appear to choose their physician in a variety a ways, with consumer activism being less influential than assumed and with many patients taking a passive role in healthcare utilization. An older study suggested that people choose their physicians largely on the advice of family and friends.

Much of the cost of medical care is borne by third party payers (insurance, Medicaid and Medicare), thus the individual responsibility for price consideration is diminished.

A recent New York Times opinion article nicely explores why patients are not simple consumers.

Have a nice weekend.

Thursday, April 21, 2011

At times, Less is More in Medicine

The Archives of Internal Medicine has a a recent and insightful editorial and series of reports on this topic.

I have been given a fair amount of thought recently on overtreatment and overdiagnosis in medicine. I am sure that I have been guilty, much like many of my colleagues, on this front. 

Often, diagnostic tests are ordered without questioning how the result will or should change patient treatment. Couple an inexperienced or uncertain doctor with an anxious patient and the potential for overtesting and overtreatment seems ripe.

Perhaps the most important point that we can learn from this editorial is that safer ways to reassure patients exist. The authors propose talking with patients as the first choice for reassurance. 

Diagnostic tests should be reserved for cases in which the benefits can be reasonably expected to outweigh the risks. The physician should understand the sensitivity, specificity of a test, along with the positive predictive value given the disease's prevalence in the community. These principles are still taught in medical school lecture halls. Somehow, they are forgotten during the course of clinical practice.

Perhaps we should begin to really drill home this message during internship as interns order more tests.

Tuesday, April 19, 2011

Outbreak at the Playboy Mansion

Source: LA Times
Hot of the infectious diseases press....or more correctly, forwarded to me by my trusty and dependable assistant, an L.A.Times news article about a whirlpool related outbreak at the Playboy Mansion.

No, this is no sexually transmitted disease, but nevertheless, of epidemiologic importance. Legionellosis was recovered from the whirlpool and is the presumed infectious agent for a large cluster of respiratory illnesses following a conference and fundraiser at the Playboy Mansion.

Legionellosis in by no means a novel pathogen, however, it appearance at the Playboy Mansion is clearly a sexy twist on a familiar foe. The LA County Health Department used social media, such as twitter and Facebook, to assist in the investigation. Cool.

If only I could get myself invited to give and infection prevention lecture there...

Monday, April 18, 2011

American College of Surgeons Valentine's Day Editorial: Beyond Bizarre

Frankly, this story is beyond bizarre.  

A New York Times blog was forwarded to me by my colleagues highlighting a Valentine's Day editorial written in the the official newspaper of the American College of Surgeons. 

The editorial was written by Dr. Lazar J. Greenfield, Professor Emeritus of Surgery at the University of Michigan and the President Elect of the American College of Surgeons. The editorial, which extols the mood-enhancing effect of semen in women and suggest that this may serve as a better Valentine's Day gift than chocolates, has launched a firestorm of criticism and concerns about sexism and anti-gay sentiments among American College of Surgeons leadership.The editorial has been removed from the organization's website. The author has apologized.

Sexism, homophobia, and racism have no presence in medicine, a profession that should not be out of touch with modernity.

Friday, April 15, 2011

Physicians Recommend Different Treatments for Patients Than for Themselves

There is a body of literature on how physicians think, i.e.- clinical diagnostic reasoning.  A good read is Dr. Jerome Groopman's How Doctor's Think.

Source: BBC
A recent paper published in the Archives of Internal Medicine explores decision making from a different perspective. 

The title is quite telling: Physicians Recommend Different Treatments for Patients Than They Would Choose for Themselves.

The investigators explore the ways that physicians' decisions are influenced by the act of making a recommendation. The study surveyed 2 representative samples of US primary care physicians—general internists and family medicine specialists. Physicians were presented each with 1 of 2 clinical scenarios. Both involved 2 treatment alternatives, 1 of which yielded a better chance of surviving a fatal illness but at the cost of potentially experiencing unpleasant adverse effects. Physicians were randomized to indicate which treatment they would choose if they were the patient or they were recommending a treatment to a patient.

For the colon cancer scenario (n = 242), 37.8% chose the treatment with a higher death rate for themselves but only 24.5% recommended this treatment to a hypothetical patient.  Among those receiving our avian influenza scenario (n = 698), 62.9% chose the outcome with the higher death rate for themselves but only 48.5% recommended this for patients.

Physicians in this study sample preferred treatments with lower chance of adverse effects, despite the potential increase in mortality. The act of making a recommendation changes the ways that physicians think regarding medical choices. This needs to be studied further.

Patient decision making is highly impacted by information asymmetry. A physician's treatment recommendation is highly valued. 

In addition to primum non nocere (first, do no harm), perhaps we should consider "recommend unto others as we would recommend unto ourselves'

Wednesday, April 13, 2011

Intranasal vaccines- Up Your Nose, Up and Coming?

Nasal spray vaccines are recently new and have been promoted as alternatives to intramuscular vaccines, especially for Influenza.

In this recent news article, investigators reported a more robust antibody response in laboratory animals when intranasal vaccines for S.pneumoniae, Influenza or Yersinia pestis (plague) were combined with interleukins. I have no reason to doubt the immunogenicity of this process.

My experience with intranasal influenza vaccine, as an Associate Hospital Epidemiolgist, at a major academic medical center, has left me less than enthusiastic.

We aggressively promote influenza vaccination, short of mandatory vaccination. Despite aggressive efforts, flu vaccine clinics, emails, alerts, reminders etc, we have difficulty vaccinating all healthcare workers. Many people cite fear of needles and injection site reactions as barriers to vaccination. So when we offered intranasal influenza vaccine, I was optimistic.

I was wrong. 

Intranasal vaccination was not widely accepted and intramuscular injection was preferred. Overall vaccination compliance did not significantly change. 

For healthcare workers, regardless of the influenza vaccine delivery method, reminders, vaccination campaigns, free vaccines, vaccination clinics and other incentives, there remains a recalcitrant fraction of non-vaccinated individuals.

Tuesday, April 12, 2011

Google Books! A Bibliophile's Dream.

What will Google think of next? They are on the road to global domination, sort of. At the very least, they have distracted me immensely today as I researched this posting and got carried away.

Yesterday, my good friend and colleague, Dr. Michael Edmond, presented an unusual case at our weekly infectious diseases case conference. During the scholarly presentation, he made reference to Ngrams and Google Books.

Google Books is an uber-search engine, which allows one to search the full text of books. Depending on the copyright status, you are able to browse full text of books on-line, and if the book is in the public domain, the book may be downloaded in PDF format. Links will allow one to borrow or buy a book.

This is truly astonishing.

A history of this digitization process is neatly summarized here. Per Google, the number of scanned books is currently at 15 million, many of which are no longer in print. The estimated world body of literary work is 130 million unique books, and Google plans to scan all of them by the end of the decade. Wow.

The literary world will be at our Google-fingertips.

I am in awe. I am inspired. I am late for work.

Monday, April 11, 2011

Mixed Bag: Trimethoprim-sulfamethoxazole (TMP-SMX ) Prophylaxis in HIV/AIDS- Impact on Bacterial Resistance

We have been using Trimethoprim-sulfamethoxazole (TMP-SMX ) for years as prophylaxis for immunosuppressed HIV/AIDS patients. I have always been concerned that TMP-SMX prophylaxis may lead to antimicrobial resistance not only to TMP-SMX, but also to other antibiotics. 

Clinical Infectious Diseases recently published an article and review of literature of TMP-SMX prophylaxis in HIV-infected and/or exposed individuals and the impact on bacterial resistance.

From a total of 501studies, only 8 studies were of high quality, of which only 2 had been specifically designed to answer this question. One good-quality study reported no change, and another good-quality study reported mixed findings; among HIV-exposed infants, TMP-SMX prophylaxis increased pneumococcal resistance to clindamycin but had no effect on pneumococcal resistance to penicillin, tetracycline, erythromycin, and chloramphenicol.

Of cohort studies assessing the impact on MRSA, the meta-analysis showed a protective effect of TMP-SMX prophylaxis on MRSA (relative risk, .29; 95% confidence interval, .12 - 0.7).

Clin Infect Dis 2011 May; 52(9):1184-94.

One study reported an increase in colonization with vancomycin-resistant enterococcus.

This is a mixed bag of results, from few quality studies. The use of TMP-SMX prophylaxis protects against MRSA infection/colonization yet may increase resistance in pneumococci and enterococci.

From my perspective, the benefits of TMP-SMX use, as prophylaxis in HIV/AIDS patients, appears to outweigh the risks of bacterial resistance.

Friday, April 8, 2011

Labyrinth of Terror: The Website and the Author

I have previously blogged about L.O.T.

Recently launched is the new website:

If you like medical thrillers, give the site, and book, a peek.

National Shortage of HIV Providers

 I have blogged about HIV epidemiology in a previous post.

The epidemiology of HIV infection in the USA is changing with 50,000 new seroconversions still reported annually. In July 2010, the Obama administration issued the National HIV/AIDS Strategy to increase access to care for people with the virus, reduce disparities in care and decrease the number of HIV infections.

Per a recent Institute of Medicine (IOM) report, as summarized in American Medical News, significant challenges remain, including limited funding and, disturbingly, a limited physician/provider workforce with specialty training in HIV.

Per the report: "The present capacity of the health care system to administer a greater number of HIV tests and to accommodate new HIV diagnoses is critically strained"'


Thursday, April 7, 2011

Hunter and the Hunted: Antibiotic Resistance, Humans and Microbes

Source: WHO
US Surgeon General,  William H. Stewart, is famously quoted  (mid 1950s) for stating  that it was “time to close the book on infectious diseases, and declare the war against pestilence won".

If only he had been correct. 

Despite advances in medicine and infectious diseases, the microbes have reared back with a global resurgence of drug resistant infections such as MRSA, MDR-Tuberculosis, Clostridium difficile, ESBL gram negative rods, and carbapenemase resistant Klebsiella pneumoniae.

The hunter (man) once again becomes the hunted. 

This global trend is being taken seriously, as witnessed by the focus on antibiotic resistance in WHO's World Health Day (April 7th, 2011). Containment of antibiotic resistance is the goal. This is achievable by the promotion of proper antibiotic use, education, policy, international surveillance and public-private partnerships to ensure the steady development of novel antibiotics.

For a well written perspective on our endless struggle with microbes, I refer you to this article in The Lancet- Infectious Diseases.

Wednesday, April 6, 2011

Measuring Infections with Multidrug Resistant Organisms: An Analysis from the Real World

Multidrug-resistant organisms (MDROs) are a growing problem. The Society for Healthcare Epidemiology of America (SHEA) and the Centers for Disease Control and Prevention’s (CDC’s) Healthcare Infection Control Practices Advisory Committee (HICPAC) published recommendations providing guidance and standardization on how to measure infection with MDROs. These include a variety of incidence and prevalence measures, as well as items such as antibiograms and line listings. 

An important question arises: how can this be implemented in the real world?

Dr. Maryam Behta, Barbara Ross, RN, both former colleagues of mine from New York City, and their collaborators, published this interesting study in ICHE assessing the challenges of applying the SHEA/CDC metrics for MDROs.

Importantly, the investigators discovered no statistically significant difference between using 72 hours or 3 calendar days as the cutoff to define hospital-onset incidence. Excluding patients not at risk (patients hospitalized for <72 hours)  from the denominator when calculating hospital-onset incidence led to statistically significant increases in rates. When excluding patients with a prior history of MRSA infection or colonization from nosocomial incidence rates, rates were similar. 

Most importantly, however, was the detailed description on data collection for each of the MDRO metrics.  Most of the metrics require some degree of electronic data extraction, a problem for hospitals without electronic medical records. Also, many of the metrics require manual review, a problem for infection prevention programs already functioning at capacity. And this is for only one pathogen, MRSA.  

If one were to fully implement the SHEA/CDC metrics for MDROs, how many full time infection preventionists would be required? Real world application is a financial and logistical challenge.

This leads me, again, to the issue of an opportunity cost. Although I work for one of the largest infection prevention programs in the country, to take on additional initiatives would require that we drop a component of our current program. Owing to a limited budgets and manpower, we choose to vigorously perform a horizontal, non-pathogen based infection prevention platform that increases implementation of infection prevention best practices and reduces all infections, by all pathogens. 

This perspective has been shared before.

Monday, April 4, 2011

Society for Healthcare Epidemiology of America Day 4- Finale

With Drs. Stevens and Edmond on an airport escalator
This morning, we heard an interesting debate that supported much of our infection prevention efforts. Save the best for last.

Back at the airport. Heading home.

Another year, another conference.

Dallas is done with us!

Sunday, April 3, 2011

Society for Healthcare Epidemiology of America Conference Day 3

Dr. Jim Pellerin presents our data on Antimicorbial Stewardship
With Kara Elam-my former research coordinator
Mike Stevens, Jim Pellerin, Kara Elam, Me
Busy day today.

Dr. Jim Pellerin, VCU Medical Intern, made us proud as he presented our Antibiotic Stewardship Program Data.

We had 5 scientific presentations today.

One day left.

Saturday, April 2, 2011

Society for Healthcare of America Day 2: Update

VCU Infection Prevention Nurse- Heather Albert, RN

VCU Infection Preventionist Heather Albert charms the crowd during Professor's Rounds.

Job well done.

Society for Healthcare Epidemiology Day 2

VCU Infection Prevention: Heather Albert, RN and Diane Heipel, RN
With VCU Infection Prevention Nurses Heather Albert and Diane Heipel at their scientific poster.

Let's hope that today's program is more engaging than last night's.

Stay tuned....