Monday, December 30, 2013

Text Messages Increase Influenza Vaccine Uptake

Here is an article on the use of text messaging to increase influenza vaccine uptake in a low-income, NYC patient population


The methodology employed was a randomized controlled trial that enrolled 1187 obstetric patients from 5 community-based clinics in New York City. The intervention group received 5 weekly text messages regarding influenza vaccination starting mid-September 2011 and 2 text message appointment reminders. Both groups received standard automated telephone appointment reminders. 

After adjusting for gestational age and number of clinic visits, women who received the intervention were 30% more likely to be vaccinated.

The use of text message reminders may be feasible within a healthcare setting, particularly regarding employee health and safety initiatives. 

Where I work, we have an annual physician and staff 'blitz' for influenza vaccination, PFR N95 mask fit testing and tuberculin skin testing. Daily or weekly text message/pager reminders might give us small boost in compliance. For the healthcare workers refusing the influenza vaccine, text message alerts about completion of mandatory declination forms may also be of value. 

Thursday, December 26, 2013

Your Dirty Laundry and Infection Control

Here is an article in Infection Control and Hospital Epidemiology on laundering scrubs at home. 

The good news: warm water (104°) with detergent was highly effective in killing MRSA and Acinetobacter. Further bacterial reduction can be achieved by ironing your scrubs.


Who has time for ironing scrubs? I prefer the dryer.

Back to work today.



Monday, December 23, 2013

Jessica Zuo in Peru

Jessica Zuo- VCU MIDPH Program 2011
Harvard graduate and former VCU MIDPH program standout, Jessica Zuo, is now  in Peru on a fellowship program where she is working with a government program serving the homeless elderly. 

Follow Jessica's work in Peru via her colorful blog here.

On a related note, Jessica's research project with us, on antimicrobial stewardship, was recently published in The American Surgeon

Kudos

Thursday, December 19, 2013

Unnecessary Antibiotics for Skin and Soft Tissue Infections

Here is an article published in The American Journal of Medicine on the unnecessary use of antibiotics for uncomplicated skin and soft tissue infections.

A total of 364 cases were included in a single center, retrospective analysis (155 cellulitis, 41 wound infection, and 168 abscess). Antibiotics active against methicillin-resistant Staphylococcus aureus were prescribed in 61% of cases of cellulitis. Of 139 cases of abscess where drainage was performed, antibiotics were prescribed in 80% for a median of 10 (interquartile range, 7-10) days. Of 292 total cases where complete prescribing data were available, avoidable antibiotic exposure occurred in 46%. This included use of antibiotics with broad gram-negative activity in 4%, combination therapy in 12%, and treatment for 10 or more days in 42%. Use of the short-course, single-antibiotic treatment strategies would have reduced prescribed antibiotic-days by 19% to 55%.
As summarized in the IDSA skin and soft tissue infections guidelines, for uncomplicated infections, especially for boils, drainage is paramount. Short courses (5-7 days) of a single antibiotic may be of minimal value following drainage.

Like with upper respiratory infections, which are typically viral, antibiotics are over prescribed for uncomplicated skin and soft issue infections.

Tuesday, December 17, 2013

Obese and Healthy?

Occasionally my obese patients challenge my suggestion that they lose weight on the grounds that they do not suffer from arthritis, hypertension, diabetes or heart disease. Therefore, is there such a thing as being healthy and overweight? Here is a paper recently published in the Annals of Internal Medicine that suggests otherwise. 

In this systematic review, eight studies (n = 61 386; 3988 events) evaluated participants for all-cause mortality and/or cardiovascular events. Metabolically healthy obese individuals (relative risk [RR], 1.24; 95% CI, 1.02 to 1.55) had increased risk for events compared with metabolically healthy normal-weight individuals when only studies with 10 or more years of follow-up were considered. All metabolically unhealthy groups had a similarly elevated risk: normal weight (RR, 3.14; CI, 2.36 to 3.93), overweight (RR, 2.70; CI, 2.08 to 3.30), and obese (RR, 2.65; CI, 2.18 to 3.12).

Compared with metabolically healthy normal-weight individuals, obese persons are at increased risk of death by all causes and for cardiovascular events even in the absence of metabolic abnormalities.

An ideal body weight is always the healthier option

Friday, December 13, 2013

Pre-Exposure Prophylaxis to Prevent HIV- Still With Limited Uptake

I previously blogged about the use of pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (Truvada) prior to high risk behaviors to prevent HIV transmission. 

Here is a recent analysis on PrEP suggesting that despite the presumed efficacy of the intervention, uptake by infectious diseases physicians is limited. In this survey, although a majority of clinicians supported PrEP, only 9% had actually provided it. 

As suggested by the article, we may not be "prepped for PrEP''.

Wednesday, December 11, 2013

Kicking for a Cause- Richmond City FC and the Fan Free Clinic

On Sunday December 8th, Richmond City FC and SCOR hosted the 9th Annual Copa Navidad.

All proceeds went to benefit the Fan Free Clinic.

Richmond City FC: Blues vs Maroon at the 2013 Copa Navidad

Monday, December 9, 2013

Glove Use- An Enemy of Hand Hygiene?

Here is an article recently published in the Journal of Hospital Infection.The researchers employed an observational methodology to assess appropriateness of glove use and hand hygiene.   

A total of 163 glove-use episodes were observed over a period of 13 h. Glove use was inappropriate in 69 out of 163 (42%) episodes, with gloves commonly used inappropriately for low-risk procedures (34/37; 92%). In 60 out of 163 (37%) episodes of glove use there was a risk of cross-contamination, most (48%) being associated with failure to remove gloves or with perform hand hygiene after use. HCW interviews indicated that the decision to wear gloves was influenced by both socialization and emotion. Key emotions were disgust and fear. 

The data on glove use are mixed. Here is one report suggesting that universal gloving may beneficial, particularly in a pediatric ICU. Concerns about the impact of glove use on hand hygiene should not be overlooked. Also, universal gloving may impact the doctor-patient relationship as explored here.

We are soon to launch a survey study of motivators and perceptions of glove use at VCU Medical Center. Stay tuned.

Friday, December 6, 2013

Supplementation of Vitamin D and Upper Respiratory Tract Infections

Vitamin D supplementation is very popular lately. Observational studies suggest an inverse correlation between vitamin D levels and upper respiratory tract infections.

Here is a recently published randomized controlled trial testing the association between vitamin D status and upper respiratory tract infection (URTI).

Seven hundred fifty nine participants were randomized to vitamin D3 (1000 IU/day), calcium (1200 mg/day), both, or placebo. Supplementation did not significantly reduce winter episodes of URTI (rate ratio [RR], 0.93; 95% confidence interval [CI], .79-1.09) including colds (RR, 0.93; 95% CI, .78-1.10) or influenza like illness (ILI) (RR, 0.95; 95% CI, .62-1.46), nor did it reduce winter days of illness (RR, 1.13; 95% CI, .90-1.43). There was no significant benefit according to adherence, influenza vaccination, body mass index, or baseline vitamin D status. Semiannual surveys of all participants (N = 2228) identified no benefit of supplementation on ILI (odds ratio [OR], 1.14; 95% CI, .84-1.54) or colds (OR, 1.03; 95% CI, .87-1.23). 

Vitamin D supplementation in adults without preexisting vitamin D deficiency may be a cure looking for an (infectious) disease.   

Wednesday, December 4, 2013

Antimicrobial Textiles in Infection Prevetion- Reviewed and Revisited

Textiles with antimicrobial properties are the ongoing rage in the infection prevention world. Here is a well written review on the matter published in Clinical Infectious Diseases.

Most technologies for surfaces and fabrics have been assessed in vitro and have been shown to reduce bacterial numbers by two logs or more. However, apart from copper -impregnated surfaces,  few antimcorbial textiles have been studied in a clinical setting.  Salgado et al published a study that assessed the impact of copper surfaces in ICUs on the rate of hospital acquired infections (HAIs). I have previously commented on this study.

We published a study on the impact of antimicrobial scrubs on heathcare worker hand and apparel bioburden. We did not assess HAI outcomes.

An important question lingers: even with effective antimicrobial textiles, what is the expected incremental impact of these technologies on HAI rates atop a robust infection prevention program with robust hand hygiene, disinfection, central line checklists, HAI bundles, chlorhexidine patient bathing, etc?

Monday, December 2, 2013

Gastrointestinal carriage of carbepenemase resistance Enterobacteriaceae- Decolonization?

CRE Map 2012; Source CDC
Can gastrointestinal carriage of carbepenemase resistance Enterobacteriaceae (CRE) be eliminated? Here is a recent publication in the American Journal of Infection Control that suggests that GI eradication of CRE is feasible.

In this cohort,  patients whose rectal isolates were gentamicin sensitive but colistin resistant were treated with gentamicin. Patients whose isolates were colistin sensitive but gentamicin resistant were treated with colistin. Patients whose isolates were sensitive to both drugs were randomized to 3 groups of oral antibiotic treatment: gentamicin, colistin, or both. Patients whose isolates were resistant to both drugs, and those who did not consent, were followed for spontaneous eradication.

A total of 152 patients were included; 102 were followed for spontaneous eradication for a median duration of 140 days (controls), and 50 received 1 of the 3 drug regimens: gentamicin, 26; colistin, 16; both drugs, 8, followed for a median duration of 33 days. Eradication rates in the 3 treatment groups were 42%, 50%, and 37.5%, respectively, each significantly higher than the 7% spontaneous eradication rate in the control group (P < .001, P < .001, and P = .004, respectively) with no difference between the regimens.CRE eradication with non-absorbable antibiotics is better than spontaenous eradication. However, the efficacy of eradication was less than superb and the results were by no means overwhelmingly positive.  Of note, no significant adverse effects were observed.

How is this applicable? Many unanswered questions remain such as what are the optimal CRE decolonization strategies? Who should be targeted? Should CRE eradication be limited to endemic settings, high risk patients (neuropenic patients) or in outbreak settings? We are far from having an optimal approach for CRE detection, isolation and eradication.






Wednesday, November 27, 2013

Medical Literary Messenger Fall 2013: Inaugural Issue Published


It is with great pride that we present you the Fall 2013, inaugural issue of the Medical Literary Messenger.


Download the issue here.

Visit the site at: www.med-lit.vcu.edu

Tuesday, November 26, 2013

Bacteremia and Mortality from a Urinary Catheter

I am back from Argentina and back to work.

Here is an investigation on bacteremia and mortality associated with urinary catheters.
The author's focused on catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU)  and studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU.

There were 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality.

Bacteremia from a urinary source was an infrequent event. In addition, there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria.  

Catheter associated urinary tract infections are the most common hospital acquired infection yet result in the least morbidity and mortality. This does not negate their relevance, however, in terms of truly impacting patient safety, the most bang for the buck is in the prevention of bloodstream infections and ventilator associated pneumonia. 

Thursday, November 21, 2013

Stethoscope Disinfection

Here is a recent publication on stethoscope disinfection.

Stethoscopes are contaminated with pathogenic bacteria and pose a theoretical risk for cross transmission.

Baskets were filled with alcohol prep pads and a sticker reminding providers to regularly disinfect stethoscopes were installed outside of patient rooms. Healthcare providers' stethoscope disinfection behaviors were directly observed before and after the intervention. Multivariable logistic regression models were created to identify independent predictors of stethoscope disinfection. 

Two hundred twenty-six observations were made in the preintervention period and 261 in the postintervention period (83% were of physicians). Stethoscope disinfection compliance increased significantly from a baseline of 34% to 59% post-intervention. In adjusted analyses, the postintervention period was associated with improved disinfection among both physicians (odds ratio [OR], 2.3 [95% confidence interval (CI), 1.4-3.5]) and nurses (OR, 14.3 [95% CI, 4.6-44.6]). Additional factors independently associated with disinfection included subspecialty unit (vs general pediatrics; OR, 0.5 [95% CI, 0.3-0.8]) and contact precautions (OR, 2.3 [95% CI, 1.2-4.1]). 

So providing stethoscope disinfection supplies and visible reminders outside of patient rooms may increase stethoscope disinfection rates. 

The intervention is simple and reasonable and is consistent with a horizontal infection prevention strategy. The actual impact on healthcare associated infections is unknown.

Monday, November 18, 2013

Friday, November 15, 2013

Congratulations Kate Pearson, Jeff Wang and Summer Donovan- VCU GH2DP Researchers at ASTMH 2013

Congratulations Kate Pearson, Jeff Wang and Summer Donovan- VCU GH2DP researchers at the American Society of Tropical Medicine and Hygiene (ASTMH) 2013 Annual Meeting.

As members of our VCU GH2DP Honduras team, they have done valuable research on health services satisfaction and chagas disease knowledge and perception.


L to R: Jeff Wang, Kate Pearson and Summer Donovan
Kate Pearson and Jeff Wang

Kudos!

Wednesday, November 13, 2013

Risk Factors for Aspiration Pneumonia- A Patient Phenotype

As a clinician I am always looking for clinical pearls. Here is a study that sought to characterize a patient 'phenotype' for aspiration pneumonia.

This was an observational study of 1348 patients hospitalized with community-acquired pneumonia in the United Kingdom. Patients "at risk" for aspiration pneumonia  chronic neurologic disorders, esophageal disorders and dysphagia, impaired conscious level, vomiting, or witnessed aspiration. 

Nearly 14% of the cohort were classified as "at risk of aspiration." These patients were older (median age, 74 years [interquartile range, 60-84] vs 66 years [interquartile range, 49-77]; P < .0001) and more likely to have comorbidities (chronic liver disease 11.3% vs 3.7%, P < .0001; congestive heart failure 28% vs 17.1%, P = .0004; and stroke 26.9% vs 9.5%, P < .0001). Patients at risk of aspiration pneumonia had a poorer short-term outcome (30-day mortality 17.2% vs 7.7%, P < .0001), but after adjusting for their greater severity of illness and comorbidities this difference was not significant (odds ratio 1.05; 95% confidence interval [CI], 0.63-1.76; P = .8). However, patients with aspiration risk factors were at greater risk of poor long-term outcomes with increased 1-year mortality (hazard ratio [HR], 1.73; 95% CI, 1.15-2.58), increased risk of rehospitalization (HR, 1.52; 95% CI, 1.21-1.91), and a strong association with recurrent admissions with pneumonia (HR, 3.13; 95% CI, 2.05-4.78) after multivariable adjustment

Using risk factors to identify patients at risk of aspiration pneumonia may give us a clinical 'phenotype' of patients with greater severity of disease and poorer long-term outcomes.

What value is this? Proving conclusively that an aspiration event caused pneumonia in clinical practice is generally not feasible. The study was also low yield with respect to microbiologic data. These data will likely not alter antibiotic management. However, a better understanding of aspiration risk and prognosis may guide discussions about realistic outcomes and limitation of treatments and may result in meaningful discussion on end of life care.

Monday, November 11, 2013

Hand Hygiene- Revisited

The issue of hand hygiene compliance continues to resurface in our discussions on infection
prevention. Here is an up to date review article on hand hygiene by Dr. John Boyce. 

New electronic methods for monitoring hand hygiene practices are increasingly popular. These interventions are expensive, likely increase compliance with hand hygiene and may be superior to compliance assessments of hand hygiene by direct observation.  As with any method of compliance monitoring, non-punitive feedback to healthcare workers is needed to further encourage improvements in practice.

However, as of today's date, I am unable to find comparative data on the incremental benefit of electronic hand hygiene technologies vs. direct hand hygiene observation with respect to increased hand hygiene compliance and decreased healthcare associated infection rates.

We still have more work to do on the practice of hand hygiene. 

Wednesday, November 6, 2013

Overt vs Covert Hand Hygiene Observers

Yesterday I spent the morning listening to presentations by vendors of new hand hygiene compliance monitoring technologies. 

In my subsequent meanderings on PubMed I came across this article in PLOS ONE documenting differences in hand hygiene compliance between overt and covert hand hygiene observers.

Of the 23,333 hand hygiene observations 76.0% were by medical students (trained, covert hand hygiene observers), 5.3% by infection control nurses and 18.7% by unit staff. The annual compliance rates were medical students (covert) 44.1%, infection control nurses (overt) 74.4% and unit staff (overt) 94.1%; P<0.001. The medical students found significantly lower annual compliance rates for 4/5 hand hygiene indications compared to infection control nurses and unit staff; P<0.05. 

The results are not surprising. The Hawthorne effect, no doubt.

Monday, November 4, 2013

Organizational Culture and Infection Prevention

Infection Prevention and the Ivory Tower of Implementation
Evidence based infection prevention initiatives may take hold in one institution yet may fail to do so in another. The concept of organizational culture (''the way things are done around here'') may come into play.

Organizational culture, explored in this article, can be equally as difficult to define as it is to change.

There is no one best approach to implementing infection prevention across a healthcare system. The process takes patience and is dependent upon the quality of the data, the organization's mission, education, marketing, champions, facilitators, measurement and feedback.  

We recently explore this theme in a publication titled Pushing Beyond Resistors and Constipators: Implementation Considerations for Infection Prevention Best Practices.

The paper will soon be published in Current Infectious Diseases Reports.

Stay tuned

Friday, November 1, 2013

Contact Precautions Revisited!

The controversy about contact precautions continues. 

I urge you to check out this post and related commentary, a proper intellectual to-and-fro, in the HAI Controversies Blog.

We eliminated contact precautions for the endemic control of VRE and MRSA at VCU Medical center on April 1st, 2013. NO, this was not an April Fool's joke.

As summarized by my VCU colleague Dr. Mike Edmond:

Here's an update: for this past quarter, hospital-wide (~850-beds) we had 1 device related MRSA infection (a CLABSI), and 2 device-related VRE infections (both CLABSI by current definition, though true source likely gut as both were oncology patients). There were no CAUTIs or VAEs associated with MRSA or VRE. No contact precautions for MRSA or VRE for the last 6 months. Housewide device days for the quarter were: urinary cath 11,807, central line 19,610, ventilator 3,431, total device days 34,848. 

Here is our perspective on contact precautions, as summarized in Current Infectious Diseases Reports.

Have a fine weekend.

Wednesday, October 30, 2013

HPV Vaccine Coverage- Disparities Abound

Today I am giving the VCU Infectious Diseases Fellowship lecture of herpes viruses and human papilloma virus (HPV) infections.

I stumbled across this recent article in Clinical Infectious Diseases on low uptake of the HPV vaccine. In this report, minority and below poverty adolescents consistently had higher series initiaion than white and above poverty adolescents.

HPV infects all and vaccination is highly effective. Socio-cultural barriers, prejudice against vaccination and misinformation on vaccine safety must all be addressed.

Monday, October 28, 2013

Influenza Vaccine and Cardiovascular Risk

Here is twist on the potential benefits of influenza vaccination. As summarized in this article published in JAMA, influenza vaccination may impact cardiovascular  risk.

The authors performed a meta-analysis with 5 published and 1 unpublished randomized clinical trials of 6735 patients (mean age, 67 years; 51.3% women; 36.2% with a cardiac history; mean follow-up time, 7.9 months).

Receipt of influenza vaccine was associated with a lower risk of composite cardiovascular events (2.9% vs 4.7%; RR, 0.64 [95% CI, 0.48-0.86], P = .003) in published trials. The greatest effect was seen  in patients with more active coronary disease.

Association does not mean causality and these results must be replicated with adequately powered, prospective, multi-center trials of influenza vaccination with specific cardiac endpoints.

Decreased cardiac risk of death may be a persuasive argument for those clinic patients insistent on avoiding influenza vaccination.

I am back on the ID Consult service this week and back to a proper daily grind.

Wednesday, October 23, 2013

Mandatory Public Reporting of Central Line Associated Bloodstream Infections- Validation is Essential

Mandatory public reporting of central line bloodstream infection (CLABSI) reporting is the norm across much of the country. Are the reportss accurate?

Here is a manuscript on validation of CLABSI reporting published in the American Journal of Infection Control. Trained Colorado Department of Public Health and Environment staff members performed onsite validation visits that included interviews with infection preventionists to assess surveillance practices and retrospective chart reviews of patients with positive blood cultures in specific intensive care units (adult and neonatal) and long-term acute care hospitals during the first quarter of 2010.

Fifty-five CLABSIs from the original sample were identified; 33 (60%) in the adult intensive care unit, 7 (12.7%) in the neonatal intensive care unit, and 15 (27.3%) in the long-term acute care hospital. Of the 55 CLABSIs identified by reviewers, 18 (32.7%) were not reported by the hospitals, 37 CLABSIs (67.3%) were reported correctly into the National Healthcare Safety Network, and 1 CLABSI was over-reported. 

Surveillance was loose with 33% of CLABSIs being under-reported.

This is concerning. Validation is essential to promote accuracy in reporting.

Monday, October 21, 2013

Medical School Curriculum on Social Justice as a Determinant of Health- The Next Generation

I believe that healthcare is a universal human right.

It is well known that social determinants
cause and impact many diseases either in resource rich or poor countries. We largely learn about disease from a biomedical perspective and generally give short shrift to social determinants of health.

Here is a an interesting article that reports a social justice curriculum at the Geisel School of Medicine at Dartmouth.The curriculum stresses physicians' obligation to participate in social justicework as an educational tool. It also emphasizes the importance of a mandatory, longitudinal, immersive, mentored community outreach practicum.

Although we advocate a biopsychosocial model of medical care, the curriculum is generally light on the ''social'' .

My hope is that this and similar social justice curricula will improve recognition and action on social determinants of disease, including access to healthcare, by the next generation of physicians.

Friday, October 18, 2013

Structured Exercise as Preventive Medicine

How well does exercise compare to prescription medications on decreasing mortality? 

Here is a study comparing prescription medications versus structured exercise.  The authors included 16 (four exercise and 12 drug) meta-analyses in the comparison. No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary heart disease and prediabetes. 

Physical activity interventions were more effective than drug treatment among patients with stroke (odds ratios, exercise v anticoagulants 0.09, 95% credible intervals 0.01 to 0.70 and exercise v antiplatelets 0.10, 0.01 to 0.62). Diuretics were more effective than exercise in heart failure (exercise v diuretics 4.11, 1.17 to 24.76). 

Of note, none of the studies reported harm from exercise.

The clinical significance? Exercise should be considered as an alternative or adjunct to prescription medications to reduce morbidity and mortality.

Take your 'exercise pill.'



Wednesday, October 16, 2013

Bundles for Hand Hygiene: An optimal Approach?

Bundles for infection prevention are now standard fare and include interventions to improve hand hygiene compliance. 

Here is a systematic review published in Clinical Infectious Diseases of studies to improve hand hygiene compliance. Of the 8,148 studies evaluated, six randomized controlled trials and 39 quasi-experimental studies were analyzed. 

Three studies evaluated the interventions education, reminders, feedback, administrative support, and access to alcohol-based hand rub [ABHR] as a bundle, which was associated with improved hand hygiene compliance (pooled odds ratio [OR]=1.82; 95% confidence interval [CI]=1.69, 1.97). Another bundle of education, reminders, and feedback evaluated in three studies was associated with improved compliance (pooled OR: 1.47; 95% CI: 1.12, 1.94).

So the optimal hand hygiene approach includes:
  • Hand hygiene education
  • Reminders and prompts
  • Hand hygiene compliance monitoring with feedback
  • Support (financial and administrative) to achieve and sustain the above 
And, once you put your foot on the hand hygiene compliance accelerator, coming off the gas will eventually bring the program's success to a halt. These are not one time interventions.

Sustainability is the key.

Monday, October 14, 2013

Perhaps MRSA is Hiding in the Gym

Here is a recent news article on MRSA affecting NFL players on the Tampa Bay Buccaneers.

Although we were unable to detect MRSA in the VCU gym in this study head authored by Dr. Dan Markley, the same may not be so for an NFL franchise.

MRSA, that pesky pathogen.

Wash your hands after gym workouts!

Friday, October 11, 2013

Contact Precautions and Patient Perception of Healthcare Quality

The body of literature on contact precautions continues to grow.

Here is a recent publication in Infection Control and Hospital Epidemiology on the association between contact precautions and patient satisfaction.

The investigators used a standardized interview to identify perceived problems with care. After discharge, the standardized interview and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey were administered by telephone. A  total of 528 medical or surgical patients were interviewed. 

Of the respondents 104 (20%) perceived some issue with their care. On multivariable logistic regression, contact precautions were independently associated with a greater number of perceived concerns with care (odds ratio, 2.05 [95% confidence interval, 1.31-3.21] including poor coordination of care  and a lack of respect for patient needs and preferences Patients under contact precautions did not have different HCAHPS scores than those not under contact precautions. 

Patients under contact precautions were more likely to perceive problems with their care, especially poor coordination of care and a lack of respect for patient preferences.

We need better data on how to best apply contact precautions and how to maximize the quality of care for patients in contact isolation.

Thursday, October 10, 2013

Clinical Significance of Mupirocin Resistance by Staphylococcus aureus

At VCU Medical Center we recently began universal staphylococcal decolonization for elective procedures in cardiac, neurosurgery and orthopedic surgery. 

Here is an article on the clinical significance of mupirocin resistance in Staphylococcus aureus published in the Journal of Hospital Infection.

Resistance to mupirocin, both high- and low-level, reduces the effectiveness of decolonizing strategies for S. aureus or MRSA. Low-level resistant isolates may initially be eradicated as effectively as susceptible isolates, but recolonization appears to be more usual. Increased use of mupirocin is associated with emergence of resistance through enhanced selective pressure and cross-transmission, however, emergence of mupirocin resistance following increased use has not been reported consistently, 

We plan to be selective with our use of mupirocin. Our decolonization strategy also includes the use of chlorhexidine body wash and Peridex gargles. 

We will be watching our infection rates very closely.

Monday, October 7, 2013

The Value of an Infectious Diseases Specialist

I spent last week at the ID Week 2013 conference.

Appropriately, the value of infectious diseases as a specialty was raised in the discussions. Here is some guidance from the Infectious Diseases Society of America (IDSA) on the value of infectious diseases as specialty. 

A nice perspective on the value of infectious diseases can be found in this 2003 Clinical Infectious Diseases article.

Value may be in the eye of the beholder. 

Back to the grind.

Thursday, October 3, 2013

ID Week 2013 The Great Ones Recognized- Dr. Richard Wenzel










I am currently at ID Week 2013 in San Francisco.

Our very own Dr. Richard Wenzel received the 2013 SHEA Mentor Scholar Award.

I can think of no better recipient as he has been a wonderful mentor to so many of us.

The Great Ones are worthy of recognition.

Monday, September 30, 2013

Arterial Catheters and Risk of Bloodstream Infection

The prevention of bloodstream infections (BSI) is typically focused on central venous catheters (CVCs).

Arterial catheters are not risk free. Here is a paper recently published in the Journal of Hospital Infection on the risk of catheter related BSI.

The Of 834 arterial catheters studied (3273 catheter-days), 109 (13%) were colonized and 11 caused bacteremia (1.3%, 3.4 per 1000 catheter-days). The majority of catheter-related BSIs were acquired extraluminally from skin of the insertion site (63%). The risk of arterial catheter-related BSI was comparable with that for short-term non-cuffed central venous catheters (2.7%, 5.9 per 1000 CVC-days).

As the most common route of infection is extraluminal, the authors make a persuasive argument for the employment of proven risk reduction interventions used for CVCs, such as chlorhexidine for cutaneous antisepsis and chlorhexidine-impregnated dressings.

I will be at the ID WEEK 2013 in San Francisco for the remainder of the week.

 I will post updates from the conference on this blog.


Wednesday, September 25, 2013

The Messy Desk Effect

Source: Guardian.com
Here is an article in the NY Times on what a messy desk may signify. 

Researchers at the University of Minnesota published this study in Psychological Science. A messy desk may produce creativity whereas order produces healthy choices, generosity and conventionality.

Perhaps I need some more disorder at my desk.


Monday, September 23, 2013

Mandatory Healthcare Reporting Laws and Impact on Central Line Associated Bloodstream Infections

Source:National Conference of State Legislatures
In the theory the mandatory public reporting of healthcare acquired infections (HAIs) should improve infection prevention best practices and decrease infection rates.

Here is an article written by my VCU colleague Drs. Amy Pakyz and Micahel Edmond. They assessed the impact of mandatory public reporting of HAIs on central line associated bloodstream infections (CLABSI).

The authors compared 159 hospitals, 92 were located in states that had CLABSI reporting and met 3 requirements, 33 were located in states that had reporting but did not meet the 3 requirements, and 34 were in states that had no legislation. 

The finding? There was no effect of state legislation group on CLABSI SIR. There were no significant differences in the mean state CLABSI SIRs among the legislation group

The reasons for this are unclear. Perhaps state reporting laws are simply not effective enough to drive practice change beyond the current CLABSI prevention programs (use of checklists, chlorhexidine skin preparation, Biopatch dressings).  In other words, atop an already robust infection prevention program, mandatory public reporting of HAIs is subject to the law of diminishing returns.

More data are clearly needed to assess the impact of public reporting on HAIs.

Friday, September 20, 2013

Fever of Unknown Origin- A Modern Perspective

The traditional definition of fever of unknown origin (FUO) is a temperature rising above 38.3°C (101°F) on several occasions over a period of more than 3 weeks, for which no diagnosis has been reached despite 1 week of inpatient investigation.

Here is an elegant perspective published in the NEJM on the new FUO, one which now includes various groups: classic, nosocomial, neutropenic,and HIV-associated.

Of note, even with advanced diagnostics, no diagnosis is made in 50+ percent of modern era FUOs. As suggested by the writer, many of these patients are critically ill with multiple conditions and devices. The (potential) causes of fever are numerous making the diagnosis increasingly more challenging.

The result, fever of too many origins (FTMO).

Vexing.


Wednesday, September 18, 2013

Self Inoculation and the Fatal Quest for the Cause of Oroya Fever and Verruga Peruana

Earlier this week I attended an excellent case presentation  by infectious diseases trainee Dr. Claudia Jarrin. The subject was Bartonella bacilliformis infection, endemic in the Peruvian Andes. Acute infection with Bartonela bacilliformis is associated with Carrion's disease (Oroya Fever) while chronic infection is the causative agent of verruga peruana.

Here is a short essay on Peruvian medical student Daniel Carrión. The paper chronicles Carrión's self inoculation, ultimately fatal, with Bartonela bacilliformis . The essay also explores other famous physician self-inoculators.

One such physician, Dr. Barry Marshall, drank an infectious broth with Helicobacter pylori, proving this as the causative organism of certain stomach and duodenal ulcers.

Marshall fared better than Carrión as he both lived and won the Nobel Prize (2005).