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.

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The authors performed a meta-analysis with 5 published and 1 unpublished randomized clinical trials of 6735 patients (mean age, 67 years; 51.3% women; 36.2% with a cardiac history; mean follow-up time, 7.9 months).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

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.

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.

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.'

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.

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!

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.

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.

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.

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.