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


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.