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

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).


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).

Monday, September 16, 2013

Global Health Revisited- Now More Interconnected Than Ever

Just the other day I attended an informative global health lecture by Dr. Michael Stevens at the VCU School of Medicine.

Highlighted in the lecture was the increased interconnectedness of populations through high volume air traffic across nations.

The short video below simulates a 24 hour global air traffic pattern. Fascinating.

The next outbreak is only an international flight away.

Friday, September 13, 2013

Nosocomial Myiasis- Bizarre

Here is a rather bizarre case of nosocomial (hospital acquired) myiasis reported in the Journal of Hospital Infection

Myiasis is infection of fly larvae (maggots in human tissue). The  larvae of Sarcophaga (Bercaeaafrica developed in an ulcer on the heel of a patient with type 2 diabetes. 

The ulcer was dressed when the deposition of larvae occurred and the rest is history. 

Wednesday, September 11, 2013

Healthcare Acquired Infection Costs- Not Inconsequential

Here is a link to a recent publication summarizing the costs of hospital acquired infections.

A similar blog post by Mike Edmond with some nice comments can be found here.

Even if the numbers are inflated, the costs of HAIs are not inconsequential.

Monday, September 9, 2013

Universal Gloving Revisited

Here is a brief invited commentary that I authored on the benefits of universal gloving. There is some evidence to suggest that universal gloving, at least during respiratory virus season in pediatric ICUs, may provide an infection prevention benefit. 

We published a controlled trial of universal gloving in a surgical ICU demonstrating that a universal gloving strategy is at least as effective as employing contact precautions. 

Universal gloving at the bedside is not a panacea. Concerns about universal gloving are not unfounded. Without doubt, donning gloves at all times puts a barrier between provider and patient, as explored in this perspective published in the New York Times.  A similar viewpoint was recently published by Dr. Karen Sibert. One author feels that gloving is the worst enemy of hand hygiene.

Apart from gloving as part of standard precautions, I am still not sure how best to employ the use of examination (non-sterile) gloves in clinical settings. 

Wednesday, September 4, 2013

Tuesday, September 3, 2013

Cohorting Patients with C.difficile Infection

Patients infected with Clostridium difficile are placed in contact isolation precautions in an single occupancy room. Is there any danger to cohorting patients with  Clostridium difficile infection (CDI)?

Here is a recent publication in he Journal of Hospital Infection assessing the risk of recurrent disease in patients cohorted with Clostridium difficile associated diarrhea.

In a UK hospital, 138 t (55.6%) CDI patients were admitted to a cohort ward. These patients were more likely to have severe CDI (odds ratio: 1.95; 95% confidence interval: 1.10–3.46; P = 0.022) and receive vancomycin (1.59; 0.94–2.68; P = 0.083) than patients who were not cohorted. Twenty-six patients (10.5%) suffered recurrence (21 cohorted and five not cohorted). Urinary infection on admission (5.16; 2.10–12.64;P < 0.001), cohorting (3.77; 1.37–10.35; P = 0.01) and concomitant antibiotics (2.07; 0.91–4.72; P = 0.083) were associated with increased risk of recurrence. On multivariate analysis, cohorting (3.94; 1.23–12.65;P = 0.021) and urinary infection (4.27; 1.62–11.24; P = 0.003) were significant predictors of recurrence.

Although there are adverse consequences of isolation, cohorting of patients with CDI is not prudent.  The benefits outweigh the risk.