Thursday, November 29, 2012

Moth Flies in the Hospital and Pesky Pathogens

Moth fly- a vector for pesky pathogens
Flies in healthcare settings are general markers of uncleanliness.

Here is an article published in the Journal of Hospital Infection on the Mediterranean moth fly (Clogmia albipunctata) in German hospitals. 

Many bacteria were isolated from these moth flies including Acinetobacter baumanniiAeromonas hydrophilaAlcaligenes faecalisBacillus cereusEscherichia coliKlebsiella pneumoniae ssp. pneumoniaePseudomonas aeruginosa,P. fluorescens and Stenotrophomonas maltophilia.

Moth flies are potential vectors of hospital acquired pathogens. 

If your hospital has moth flies, be concerned. 

Monday, November 26, 2012

Zero Infections in Healthcare- Revisited

I spent much of the weekend updating a lecture of infection prevention. The theme of 'zero' healthcare infections is one of the themes covered in the lecture.

Can all healthcare associated infections be prevented? This is a controversial subject and the current data suggest that the goal of zero infections is illusory. Here is a an important paper published in Infection Control and Hospital Epidemiology on estimating the proportion of healthcare associated infections that are reasonably preventable. As many as 65%-70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI may be preventable with current evidence-based strategies.

In my opinion the state of infection prevention science is not robust enough to prevent all infections. The goal should be to fully and consistently implement evidence based infection prevention best practices to maximally reduce infection risk. 

For a scholarly perspective on 'Getting to Zero,' I refer you to this publication by my friend and colleague Dr. Michael Edmond.

Friday, November 23, 2012

Hospital Bed Alarms- What is the Benefit?

There is much discussion in my line of work on improving patient safety, particularly related to hospital acquired infections. But patient safety is not limited to infectious diseases.

Patient falls are a major safety issue and hospitals are required to implement and evaluate a falls reduction program for ongoing accreditation by the Joint Commission. Decreased patient falls are associated with hospital Magnet status and quality of nursing.

It seems like we are always searching for new technologies to enhance patient safety in healthcare. One such related technology are bed alarms.

Are bed alarms useful for the actual prevention of patient falls? Here is a single center, cluster-randomized trial on the effectiveness of bed alarms on patient falls published in the Annals of Internal Medicine.  Although the intervention was successful in increasing the use of bed alarms, there was no significant impact on fall-related events or the use of patient restraints.

This paper may serve as a warning on technology over reliance and reminds us that minimizing patient fall risk is multifactorial, requiring a coordinated effort, as outlined here by the Veterans Affairs National Center for Patient Safety.  

No one said it would be easy.

Wednesday, November 21, 2012

UN Global Aids Report 2012

World AIDS Day 2012 is around the corner so please pay attention to the related events in your area.

Here is a link to the the UN AIDS Global AIDS report 2012.

Here are my comments at the VCU School of Medicine 2009 World AIDS Day Luncheon-Lecture.

Monday, November 19, 2012

Isolation of HIV Positive Inmates: Not based on Science

The Alabama Department of Corrections has a policy to isolate all HIV positive prisoners. HIV positive inmates are housed in special dorms with air conditioning and a private cell. However, there are restrictions. Inmates eat alone, not in the cafeteria and must  wear white plastic armbands identifying them as H.I.V. positive. Also, inmates are not allowed to work around food. Read about it here in this NY Times Article.

I suspect  that any infectious diseases specialist will tell you that this isolation policy of HIV positive inmates is misguided. HIV is not spread by casual contact or by airborne transmission. Prison officials fear that HIV will spread through consensual sex, through rape or through blood when inmates give one another tattoos.

For a data driven approach to limit the spread of HIV, either in prison or elsewhere, diagnose the disease early by offering voluntary, accessible testing and treat to prevent disease transmission and disease progression.

Friday, November 16, 2012

Going Truly Organic: Unpasteurized Milk and Infectious Diseases

Like many, I prefer the organic foods section of the grocery store, however, I do have my limits. 

Here is an interesting article, published in Clinical Infectious Diseases, that reminds us of the perils of consuming unpasteurized, straight from the farm, organic milk.  In this case, an outbreak of Q fever was reported from a Michigan dairy.

Raw milk consumption has increased in popularity with many people purchasing milk directly collected from a dairy milking parlor. Although direct purchase of raw milk is illegal, purchase through a cow share arrangement is not. Such dairies are not inspected by regulatory authorities and are not expected to meet minimum safety standards.

Consuming raw, unpasteurized milk is associated with infectious diseases health risks. But, don't just take my word for it, read about it here from the CDC.

Wednesday, November 14, 2012

Congratulations Jackie Arquiette: American Society of Tropical Medicine and Hygiene Annual Meeting 2012

Jackie Arquiette at ASTMH 2012
Congratulations to VCU 2nd year medical student Jackie Arquiette for presenting her work at the American Society of Tropical Medicine and Hygiene Annual Meeting  on November 14, 2012. 

Jackie's  work focused on measuring clinical and microbiological efficacy of water filtration systems in rural, mountainous Honduras. 

Her research is referenced in our most recent Internal Medicine Grand Rounds presentation.


Tuesday, November 13, 2012

Congratulations Audrey Le: American Society of Tropical Medicine and Hygiene Annual Meeting 2012

Audrey Le at ASTMH 2012
Congratulations to VCU 2nd year medical student Audrey Le for presenting her work at American Society of Tropical Medicine and Hygiene Annual Meeting  on November 12, 2012. 

Audrey's work focused on indoor air pollution in rural Honduran homes, as part of our ongoing medical relief work. Her research is referenced in our most recent Internal Medicine Grand Rounds presentation.


Eyeglasses for the Developing World- A Vision for the Future

The developing world is full of health problems. One of the many is the lack of prescription eyeglasses. Last year we took 170 pairs of glasses to Honduras on our medical relief trip. They were a hot commodity.

How could prescription glasses be delivered to millions of people in resource poor countries in a cheap and simple fashion? Below is an informative TED video on the subject brought to my attention by a colleague at VCU Medical Center.

Could we do the same for water filters? Specifically, could we teach the campesinos targeted by our yearly medical relief trips to make and maintain their own clay water filters for enhanced water sanitation? This is worth exploring.

To learn more about our ongoing clinical work, public health projects and research in Honduras, visit the the GH2DP website or peruse the slides from our latest presentation, at VCU Internal Medicine Grand Rounds.

Monday, November 12, 2012

Asymptomatic Bacteriuria in Young Women with Recurrent Urinary Tract Infections: Is treatment Necessary

Here is an article that I will discuss with our infectious diseases trainees later in the week.The clinical question is as follows: in young women with recurrent urinary tract infections, should asymptomatic bacteriuria (bacterial colonization of the urine) be treated?

The investigators used a prospective, non-blinded,  randomized  methodology to compare treatment to no-treatment of asymptomatic bacteriuria in a total of 637 women. 

The result? At the last follow-up, 41 (13.1%) in the no treatment group and 169 (46.8%) in treatment group showed showed symptomatic urinary tract infection recurrence (RR, 3.17; 95% CI, 2.55-3.90; P < .0001).

The message: don't treat urinary colonization with bacteria, only treat active infections! 

The indiscriminate use of antibiotics leads to selection of resistant pathogens and likely alters the normal colonic and vaginal flora. The intestinal and vaginal bacteria are important defense mechanisms against invasion of the urinary tract by E.coli.

Friday, November 9, 2012

Fluoroquinolones and the Risk of Cardiac Arrythmia

Fluoroquinolones have been suspected to cause cardiac arrhythmia. I was intrigued by this article that assessed the risk of serious arrhythmia, defined as ventricular arrhythmia or sudden/unattended death related to fluoroquinolones.

The investigators used a cohort of patients treated for respiratory conditions from 1990 to 2005. A nested case-control analysis was performed within this cohort. Cases were matched with up to 20 controls. Conditional logistic regression was used to compute adjusted rate ratios (RRs) of serious arrhythmia associated with fluoroquinolone use.

Of the 605,127 subjects, 1838 cases of arrythmia were identified (incidence = 4.7/10 000 person-years). The rate of serious arrhythmia was elevated with fluoroquinolone use (RR = 1.76; 95% confidence interval [CI], 1.19-2.59), in particular with new current use (RR = 2.23; 95% CI, 1.31-3.80). 

Gatifloxacin use was associated with the highest rate (RR = 7.38; 95% CI, 2.30-23.70); moxifloxacin and ciprofloxacin were also associated with elevated rates of serious arrhythmia(RR = 3.30; 95% CI, 1.47-7.37 and RR = 2.15; 95% CI, 1.34-3.46, respectively).

I have yet to see a case of cardiac arrythmia attributed to a fluroquinolone antibiotic and these are used quite frequently. The risk is very small yet real. Nevertheless, the above study serves to remind us that antibiotics should not be used indiscriminately as there is potential for serious harm.

Like the scalpel, the prescription pad can be lethal if used inappropriately.

Thursday, November 8, 2012

VCU Global Health in Rural Honduras: A 7 Year Journey

Today Dr. Stevens and I presented our 7 year Honduras journey at VCU Internal Medicine Grand Rounds.

The lecture, in PDF format, can now be found here.

Tuesday, November 6, 2012

Disparity in Infection Control Practices for Multi-Drug Resistant Gram Negative Rods

The application of contact isolation precautions can be disparate. Here is a previous blog related to contact isolation uncertainties

Today I came across this manuscript reporting on the disparities in infection control practice for the control of multi-drug drug resistant gram negative rods (extended-spectrum β-lactamase-producing Enterobacteriaceae [ESBL-E] and carbapenem-resistant Enterobacteriaceae [CRE]).  The study was a survey based across 15 hospitals in Toronto, Canada. There was wide variation in the use infection control practices including admission screening (53% and 53%), contact precautions (53% and 100%), and isolation (60% and 100%) for ESBL-E and CRE, respectively. For  the hospitals performing admission screening, 75% used risk factor-based screening for ESBL-E and CRE.

Why? Most likely because high quality data and consensus guidelines are lacking on how best to detect and isolate patients colonized or infected with these pathogens. In addition, effective decolonization methods and evidence based protocols for discontinuing isolation are still undefined.

For our recent perspective on contact precautions, click here

It is November 6 and the polls just opened. I am walking out to vote. Who will get my presidential vote? You will just have to guess.

Monday, November 5, 2012

Orthorexia nervosa

I am treading well beyond my area of medical expertise today, hence, I will be brief. This morning I came across an article on orthorexia nervosa in an Argentine newspaper.

There are people overly concerned about having a perfect diet, resulting in a maniacal obsession for healthy foods, as summarized here in the journal of Eating and Weight Disorders. I also came across this article, published in Appetite, on the prevalence of orthorexia nervosa in resident physicians in a Turkish hospital. The prevalence seemed disturbingly high.

It is clear from my brief search of PubMed that orthorexia is a relatively new diagnosis with a small corresponding body of medical literature. The adverse health consequences of orthorexia have yet to be fully detailed in the peer reviewed literature. 

Regardless, when seeking healthy foods becomes an overwhelming drive with obsessive-compulsive components, it is time to seek help.

Friday, November 2, 2012

Racial Disparities in HIV Infection in the USA

Here is a recent article that speaks volumes and accurately reflects my day to day observations in the HIV clinic. There is a growing disparity in the rate of HIV/AIDS diagnoses in young men, particularly young, black men ages 15-24. 

This is a sad and disturbing trend, particularly as risk reduction interventions, HIV testing and treatment are all more accessible than ever.
Our ongoing efforts to reduce the incidence and burden of HIV must be focused and prioritized for this high risk group.