Fever- The Story of Typhoid Mary

For those of you looking for a good medical read, I would suggest Fever, by Mary Beth Keane. This medical novel focuses on the life of Mary Mallon, infamously known as Typhoid Mary.

The narrative goes beyond depicting the medicine and evolving understanding of infectious diseases at the turn of the 19th century. At its core is a deep and meaningful story about love and survival. 

Despite the sickness and death inflicted by a Marry Mallon, one cannot help but sympathize with her struggle and see her as a sadly forgotten heroine of an era long past.

Well worth reading.

University of Nebraska Biocontainment Unit Visit

I have spent the last few days at the University of Nebraska at the Ebola Training Course. This was an excellent experience and will definitely improve the finalization of the VCU Unique Pathogens unit, which is imminent.

Back to Richmond tonight and back to ID consults tomorrow.

What is the optimal number of infection preventionists for a hospital?

What is the optimal number of infection preventionists for a hospital? The conventional is estimate is that one infection preventionist is needed for every 250 acute care beds.  Here is a recent article in the American Journal of Infection Control that explores an alternative formula for calculating the number of infection preventionists in a hospital. The formula assigns an 'acute care bed equivalent' to different hospital variables (ICU bed, Long Term Care, Dialysis facility, ambulatory clinic, ambulatory surgery center). The goal is to adequately capture the increased work demand  through bed adjustment.

In my opinion, the times have changed. Now, the scope of infection prevention goes far beyond performing surveillance and reporting infection rates. The onus is on us to promote and engineer best practices for the healthcare system. In other words, we are meant to play a fundamental role in implementing, measuring and sustaining best practices in infection prevention (central line checklists, hand hygiene, head of bed elevation, chlorhexidine bathing, review of urinary catheter use, staphylococcal decolonization).Our role is active and much less passive than the historical norm.

The new paradigm is on preventing infections and that takes significant time and energy. Accurately capturing this effort may require more than infection prevention staffing by bed adjustment.

We are still searching for the optimal measurement of infection prevention staffing needs. 

Bare Below the Elbows Spoofed at VCU Medical Center

You can never to be too serious. 

Below is a funny spoof by VCU School of Medicine students on our bare below the elbows infection prevention strategy. All of the comments and actions are very tongue in cheek.

Medical Literary Messenger Fall 2014- Published!

The Fall 2014 Medical Literary Messenger is now published.

Message from the Editor:

Our adventure with the Medical Literary Messenger continues. We received the largest number of submissions to date and have selected a collection of essays, poems and images
that represent both the depth and creativity in which we hope to observe and understand the experience of medicine and disease.

Without you, both the readers and contributors of the Medical Literary Messenger, the whole of the project would be less than the
sum of its parts.

Antimicrobial Scrubs- Still Looking for the Magic Bullet

This article, a randomized trial to decrease bacterial contamination of scrubs in a hospital setting, caught my eye over the weekend.

The investigators employed a prospective, randomized, cross-over study design to assess the impact of antimicrobial scrubs (Chitosan-Sanogiene) in 110 healthcare workers. At study conclusion, 30% of scrubs were contaminated with pathogenic bacteria, including S.aureus. There was no difference in bacterial contamination between standard and study scrub.

The science of antimicrobial scrubs is imperfect. We published a study of antimicrobial scrubs demonstrating a reduction in some bacterial counts (MRSA) but not VRE and gram negative rods. The hands of the HCWs were equally colonized regardless of the attire type.

To date, we do not know the proportionate impact of apparel on hospital acquired infections. Healthcare worker hands are colonized with pathogenic bacteria regardless of attire choice. Cross transmission of pathogens in the hospital is still most likely via the hands of the healthcare worker.

We are still searching for the infection prevention magic bullet.

12th and Marshall: What Not to Wear

The Virginia Commonwealth University School of Medicine has a new Alumni magazine titled 12th and Marshall.

I was recently featured in an article titled What Not to Wear.

The genesis of the VCU bare below the elbows infection prevention recommendation is from Mike Edmond, as neatly summarize in My New White Coat is a Cool Black Vest.

Change is afoot.

Fear, Ethics and Ebola

It seems that Ebola preparedness continues to occupy much of my time. My blogging has been very ''light'' as of the last month or so.

I came across some interesting articles this past weekend. Here is a thought provoking article in the New York Times on the ethics of infection. In particular, the author explores the ethical obligation of a potentially infected person, such as a healthcare worker who has cared for an Ebola patient,  to personally limit contact with others. This is an important concept as the notion of the collective good is frequently counter cultural in the USA, where individual rights prevail.  

The NY Times Magazine article on fear and Ebola by Abraham Verghese is a worthy read. Dr. Verghese likens much of the current Ebola fear to that of the panic in the early 1980's with the appearance of AIDS. Public fear can lead to concerning negative consequences such as punishing healthcare workers rather than rewarding them after they put themselves at risk by caring for patients with Ebola. We do not need fewer volunteers in this crisis.

Misguided and misinformed notions can significantly stifle the dangerous and laudable work that is required to limit the current Ebola epidemic.

Visiting Professorship, Airport Screening for Ebola

Medical Library- University at Buffalo

I spent last week at the University at Buffalo School of Medicine and Biomedical Sciences as a visiting professor (Infectious Diseases). Given that UB Med is my medical Alma Mater, this was a huge honor for me.

Butler Auditorium- University at Buffalo

I am back at VCU, seeing patients and collaborating with many others on our ongoing Ebola preparedness. Although not immediately relevant to our Hospital Infection Prevention Program, I am frequently asked my opinion on airport screening and travel bans. 

This editorial published in  the British Medical Journal summarizes much of the key arguments on Ebola screening at airports. Even as we embark on airport screening, we should not fool ourselves that it will be an effective mechanism to limit the entry of Ebola into the USA. A review of the evidence, particularly for mass screening at airports during the SARS epidemic, suggests that screening, including thermal scans, will detect few cases. Many will not self report symptoms. Also, the longer the incubation period of the infection (up to 21 days for Ebola), the greater the chance of being asymptomatic at the time of screening.

Airport screening may give us a false sense of security. Efforts and resources should be directed at mass public health messages on where to seek prompt medical care  for those at risk of Ebola virus disease. 

More importantly, resources are needed on the front, in west Africa.

Ebola and RVA

The last 72 hours have been exceedingly hectic as we worked through a suspected Ebola case. In the end, the much feared infection was excluded. As with many crises, many lessons are learned and many issues are still evolving.

The Richmond Times Dispatch published this editorial on our response to the Ebola threat. Today, our very own Dr. Richard Wenzel published this thoughtful commentary in the Richmond Times Dispatch. 

Other recent media include these print interviews where I am quoted, accessed here and here. A recent Channel 12 interview can be viewed here while a Channel 8 appearance is accessed here.

ID Week 2014

With Nadia Masroor at ID Week 2014

Last week was exceedingly busy at the ID Week 2014 conference. In addition to various SHEA related committee meetings, we presented our data on de-escalation of contact precautions for endemic MRSA and VRE (Presented by Dr. Michael Edmond).

Nadia Masroor presented our scientific abstract on perceptions and barriers to universal gloving.

Now I am back to work, back to the grind and back to Ebola emergency preparedness. 

Enterovirus and Ebola Media Attention

The last several days have been a bit of a media frenzy with Enterovirus and Ebola, both locally and nationally.

Here is a link to a WRIC Channel 8 television interview I did on both Enterovirus and Ebola.

Here is a link on another interview, with a focus on Ebola, for CBS Channel 6.

I also participated in a live Twitter chat, accessed here.

Death in the White House: William Henry Harrison

I am back on the infectious diseases consult service this week so my attention will be diverted to clinical care. Regarding infectious diseases cases, here is an interesting article published in Clinical Infection Diseases titled Death in the White House: President William Henry Harrison's Atypical Pneumonia.

The article challenges the long maintained notion that pneumonia killed William Henry Harrison (1773-1841) just 1 month after he became the ninth president of the United States. A careful review of the detailed case summary written by his personal physician suggests that enteric fever, not pneumonia, was the disorder that killed the president.  

Although President Harrison did have some pulmonary symptoms, the case summary highlights the progressive abdominal symptoms that ultimately led to sepsis and death. Emphasis is placed on the unsanitary condition of early 19th century Washington, DC. The water supply of the White House was 7 blocks down from a repository of ''night soil", a euphemism for human feces. Given that a sewage system was non-existent, runoff most likely contaminated the water supply, increasing the likelihood of enteric fever. 

I previously blogged about the death of President Garfield, as chronicled in the Destiny of the Republic, another worthwhile read.

Then, as in now, physicians subscribed to the tenet of primum non nocere. Ironically, unbeknownst to them, the treatments, both in the cases of Presidents Garfield and Harrison, were toxic and led to greater harm than good. 

Good intentions, bad results.

Seeing the Invisible

I am back to my medical blog after a much needed break.

In honor of Anton Van Leeuwenhoek, the founder of the microscope, I refer you to this animated video from the New York Times titled Seeing the Invisible.

As an infectious diseases specialist I have plenty of respect for microbes. The goal is not to kill or eradicate all bacteria, rather, to target treatments such as to minimize adverse consequences, maintain our homeostasis and preserve the symbiosis between man and microbes.

A Systematic Review of Mandatory Influenza Vaccination in Healthcare Personnel

Here is an article published in the American Journal of Preventive Medicine that provides the most up to date assessment of mandatory influenza vaccination of healthcare workers.

This can be a very emotionally charged subject for many people. What evidence is there to support mandating the influenza vaccines in healthcare workers?Twelve observational studies were included in the study from 778 citations. The data suggest that implementation of a vaccine mandate will without doubt increase vaccination of healthcare workers, exceeding 94%. 

But what are the health benefits for healthcare providers and patients? This is much less clear. Two single-institution studies reported limited, inconclusive results on absenteeism among healthcare workers. We still cannot answer whether vaccination will result in fewer sick days by staff. Importantly, no studies reported on clinical outcomes among patients. 

We simply do not know if mandatory vaccination of healthcare workers will result in improved patient safety as the appropriate studies have not been done.

Mandatory influenza vaccination of healthcare workers is not backed by sound evidence, either for staff or patient outcomes. This is disappointing and mandatory vaccination may be an overreach.

Fortunately, the vaccine is safe.

What Can Fourteenth Century Venice Teach Us About Ebola?

Plague Doctor's Mask

What can fourteenth century Venice teach us about Ebola? 

Here is an interesting perspective published in Environment Systems and Decisions. Venetian authorities focused on managing physical movement, social interactions, and data collection for the city as a system. This included the creation of lazarettos (quarantine stations) on nearby islands, quarantine periods, and wearing protective clothing (plague doctor's mask).

With the present Ebola outbreak, we are reminded of the importance of emergency preparedness, patient isolation for infection prevention, the use of personal protective equipment and the need for cultural/practice changes in African countries (limiting both contact with sick individuals and post-mortem contact) so as to further limit person to person cross transmission.

Plague and Ebola, different illnesses, different pathogens, some historical parallels.

Flashing Lights and Alcohol-Gel Dispensers- Improving Hand Hygiene Compliance

I am always looking to new approaches for increasing hand hygiene compliance. Here is an article published in the American Journal of Infection Control that caught my eye.

The investigators used a simple red light flashing at 2-3 Hz affixed to the alcohol gel dispensers, within the main hospital entrance.. Baseline and intervention observations were completed over five 60-minute periods (Monday-Friday) from 7:30 to 8:30 AM using a covert observation method.

Baseline hand hygiene compliance was 12.4%. The intervention increased compliance to 23.5% during cold weather and 27.1% during warm weather.

Really? Do we think that this will have a significant and lasting impact of hand hygiene compliance and infection prevention outcomes? 

I doubt it.

In my opinion, hand hygiene programs should preferentially focus on staff, use education, prompts, maximize accessibility of hand sanitizers, employ observation and feedback, and if feasible, employ automated hand hygiene monitoring technologies.

The blink red light is not sufficient.

Ebola Virus Preparedness in US Hospitals- An Emerging Disconnect

As the Ebola outbreak continues to evolve and as US hospitals prepare for the imminent arrival of additional cases stateside, a disconnect is emerging between recommendation and practice. 

For example, the Centers for Diseases Control recommends that health care workers treating Ebola patients need only wear gloves, a fluid-resistant gown, eye protection and a face mask to prevent becoming infected with the virus. Patients should also be placed on contact and droplet precautions.

Where I work, and elsewhere, the fear of Ebola infection by HCWs is driving more aggressive infection prevention measures. The phenomenon is nicely summarized in the NY Times article. In addition to the isolation of patients in airborne and contact precautions, we have dedicated personal protective equipment for the care of Ebola infected patients, this includes Tychem suits, double gloves, PAPRs and fluid resistant booties over the Tychem suit.

Although the minimal standards for isolation and personal protective equipment set by the CDC for the care of Ebola infected patients is likely sufficient, the cross transmission of Ebola from a patient to a HCW in a US hospital would, in my opinion, result in near mass hysteria.

A heightened infection prevention strategy for the care of Ebola infected patients may not be unreasonable.

Ebola Preparedness- VCU Interview

I have been asked by some about where to find my recent Channel 12 interview on Ebola preparedness.

The interview may be found here.

What Not to Wear (In the Hospital)!

What not to wear (in the hospital)! The VCU School of Medicine will launch a new glossy publication (print and web) this Fall. One of the featured articles will be on healthcare worker attire.  

This piece is partly motivated by the SHEA Expert Guidance Paper of Healthcare Personnel Attire in Non-Operating Room Settings which I co-authored with various colleagues from the Society for Healthcare Epidemiology of America.

In the photo shoot, we captured images of traditional physician attire and that of bare below the elbows approach for inpatient care.  At VCU Medical Center, the Infection Control Committee recommends bare below the elbows for inpatient care. The aim is to promote hand hygiene to the level of the wrists and to prevent infrequently laundered items, such as lab coat sleeves, from coming into contact with patients and the patient care environment.

For many, the white coat has a utilitarian function with its pockets. We have learned, from a study in our institution, that the need for carrying capacity is an ongoing motivator for wearing a white coat. The black vest, with its pockets, serves as a reasonable substitute to the white coat and allows for a bare below the elbows approach to inpatient care.

The concept of the black vest as the new white coat was originally conceived by my friend and colleague Dr. Michael Edmond, and is neatly summarized here.  

Stay tuned.

The Fist Bump - A More Hygienic Salutation?

The handshake is firmly rooted in Western culture as salutation. It is well known that many

pathogens, particularly respiratory viruses, can be cross transmitted by contact.

Could the fist bump be a more appropriate salutation as an infection prevention measure? Here is an intriguing read on the fist bump recently published in the Journal of Hospital Infection.

The authors suggest that implementing the fist bump in the healthcare setting may reduce bacterial transmission between healthcare providers by reducing contact time and total surface area exposed when compared with the standard handshake. In the small study, significant differences in contact surface areas were observed between the palmar surface area, contact time of the handsake was 2.7 times longer than a fist bump and total colonization of the palmar area of the hand was four times greater than the fist after incubation at 72 hours. 

Some important limitations should be noted, specifically, the bacteria were not speciated so the presence of MRSA, VRE and gram negative rods is speculative, and, the study did not target outcomes such as hospital acquired infections. Regardless, the idea of encouraging a fist bump is not ridiculous as it is supported by biological plausibility.

Changing hospital culture is tough enough, changing social norms, such as changing a hand shake to a fist bump, may even be more challenging. 

Yogurt and C.difficile Infections in the Hospital

Here is an intriguing report in The Hospitalist on encouraging the consumption of yogurt by hospitalized patients receiving antibiotics. The health system performing this intervention reported a significant decrease in the rate of C.difficile associate diarrhea.

I have multiple reasons to be skeptical. First, I cannot find this report cited in any peer reviewed, medical journal. How can one be sure that introduction of a 'yogurt diet' was causally related to a change in C.difficile rates? What about other important factors such as changes in antibiotic stewardship, hand hygiene practices, length of stay, changes in room disinfection? Too many unanswered variables and the study design was not rigorous.

Also, the largest, most recent probiotic trial failed to show benefit on preventing C.difficile associate diarrhea. 

Yogurt will likely not impact  C.difficile in acute care settings.

The Rushed Doctor

I am a bit off topic as this is not related to infectious diseases.

Here is a telling editorial published in the New York Times on the rushed doctor. The bottom line, in attempt to accommodate the growing numbers of patients, encounter times are decreasing. This may not be the best for patient safety, satisfaction and outcomes.

In my institution, we have yet to feel the time pinch as acutely. We still are allowed 30 minutes for a follow up visit and 60 minutes for new patient. Owing to overbooking of cases, admittedly self imposed to accommodate the clinical demand, time pressure does become a factor

Another recent editorial refers to the bottleneck in training doctors.

Challenging.

Hand Hygiene and Video Observation in the Operating Room

In my institution, we are launching into an initiative for enhancing hand hygiene (HH) in the OR. Although the surgical hand scrub is an inviolate ritual in the surgical arena, hand hygiene in and around the OR is much less robust. The body of literature on HH in the OR is much smaller than in non-OR settings.  Here is an article on the use of video observation for HH monitoring that was recently published in the the American Journal of Infection Control.

The investigators used video observation in the OR to map patterns of anesthesia provider hand contact with anesthesia work environment (AWE) surfaces and to assess HH compliance. The World Health Organization criteria for HH was used as the HH standard. Serial bacterial cultures of high contact objects were performed to characterize bacterial transmission over time.

A low rate of HH compliance by anesthesia providers was observed (mean, 2.9%). Most importantly - an inverse correlation was observed between provider hand hygiene compliance during induction and emergence from anesthesia (3.2% and 4.1%, respectively) and the magnitude of AWE surface contamination (103 and 147 CFU, respectively). 

We need better mechanisms to both encourage HH and to make it feasible in an OR, particularly at the anesthesia work station. This will require education, promotion and feedback.

The benefits of improving HH in the OR is based on biological plausibility. The real impact of HH on surgical site infection remains unknown. This knowledge gap poses a problem for implementation and ''buy in'' from healthcare workers.

An uphill climb looms.

VCU MIDPH 2014- Congratulations to VCU Medical Students Sarah Hughes and Tammy Tran

Congratulations to VCU Medical Students Sarah Hughes and Tammy Tran, who presented their Microbiology, Infectious Diseases and Public Health Program (VCU MIDPH) summer research on July 7, 2014.

Sarah's work focused on infection prevention strategies in the medical ICU and Tammy studied Lyme disease ecology and climate patterns.

Kudos to both.

Asymptomatic Bacteriuria and Prosthetic Joint infection- Less is More

I am back on the ID consult service today. This will certainly keep me busy and conflict with viewing the World Cup games. 

Here is an intriguing article in Clinical Infectious Diseases that caught my eye this weekend.This was a multicenter study of patients undergoing total hip or total knee arthroplasty. A urine sample was cultured in all patients, and those with asymptomatic bacteriuria were identified. A total of 2497 patients were enrolled. The prevalence of asymptomatic bacteriuria was 12.1% (303 of 2497), 16.3% in women and 5.0% in men (odds ratio, 3.67; 95% confidence interval, 2.65-5.09; P < .001). The overall prosthetic joint infection rate was 1.7%. The infection rate was significantly higher in the asymptomatic bacteriuria group than in the non-asymptomatic bacteriuria group (4.3% vs 1.4%; odds ratio, 3.23; 95% confidence interval, 1.67-6.27; P = .001). 

But here is the most intriguing finding: in the asymptomatic bacteriuria group, there was no significant difference in joint infection rate between treated (3.9%) and untreated (4.7%) patients. Also, prosthetic joint infections did not correlate to isolates from urine cultures!

To me this underscores, again, that asymptomatic bacteriuria should not be treated except in pregnancy and in patients about to undergo invasive bladder procedures. Treatment of asymptomatic bacteriuria does not impact outcomes and likely breeds antibacterial resistance. 

With respect to treating asymptomatic bacteriuria, less is more.

The Staphoscope- A Potential Vector for Healthcare Associated Infections

I have previously blogged about our dirty stethoscopes (staphoscopes) and about possible disinfection strategies at the point of care. 

Here is a recent entry from the National Patient Safety Foundation Blog on 'Foaming in and Foaming Out,' both in the context of hand hygiene and stethoscope disinfection. 

An ongoing challenge for infection prevention professionals is accurately estimating the degree to which an instrument such as a stethoscope is responsible for hospital acquired infections. This would support the argument of decontaminating stethoscopes and any other material which comes into direct contact with patients in the clinical environment.

Much like hand hygiene, the disinfection of stethoscopes will require a behavioral change, aided by education, ubiquitous access to disinfection wipes, observation, feedback and accountability. 

To date, there is no prospective study assessing the impact of stethoscope disinfection on the rate of hospital acquired infections so making a convincing argument in favor of a behavior change is based on commonsense and biological plausibility. 

Changing behavior is much easier said than done.

World Cup Time- Why So Many Soccer Fans Dislike Argentina

I have taken a break from blogging as of late, the reasons are multiple. The most immediate reason is that the World Cup has diverted my attention.

Being both a soccer player, albeit over the hill, and an Argentine, the title of this article in the NY Times was eye catching.

I certainly hope that we win the World Cup. Being boastful and arrogant never gets you too far.

In sport or otherwise, it is helpful to remember the following: 
All Glory is Fleeting- General George C. Patton

Medical Literary Messenger Spring 2014 Published

The Spring 2014 issue of the Medical Literary Messenger, which I oversee as the Editor-in-Chief, has been published.

You may download it via the website here.

I am very proud of the work of our contributors and of the editorial team. 

I hope that you will find the latest issues engaging, reflective and touching.

Illness in Travelers Returned from Brazil- Implications for the 2014 FIFA World Cup

A came across this article in Clinical Infectious Diseases that deals with both infectious diseases and football (soccer). Naturally, I was thrilled.

In this retrospective review the most common travel-related illnesses were dermatologic conditions (40%), diarrheal syndromes (25%), and febrile systemic illness (19%). The most common specific dermatologic diagnoses were cutaneous larva migrans, myiasis, and tungiasis. Dengue and malaria, predominantly Plasmodium vivax, were the most frequently identified specific causes of fever and the most common reasons for hospitalization after travel. 

Cutaneous larva migrans should be no surprise, given that Brazilian beaches are teeming with hookworms. In one report, 30 % of beach sand sampled from Alto Beach in Brazil contained the larvae of the dog and cat hookworms. Beach sand is also a hazard stateside, as summarized in this past blog of mine.

I am not suggesting that one attend the World Cup exclusively for the matches and then return immediately to the hotel. Some common sense precautions may help, such as wearing flip flops and  lying on beach recliners to minimize direct contact with beach sand. Hand hygiene and travel appropriate vaccinations would also help to prevent other ailments.

It is World Cup Time. Olé! 

Fecal Transplantation- A Huge Step Forward

I have been silent on the blog for a bit. I am back!

Last week, I performed a fecal microbiota transplant (FMT) for refractory C.difficile infection. My colleague at VCU, Dr. Michael Edmond, is truly a leader in this important treatment, as suggested here.

A major barrier to FMT is obtainment of the donor stool. Enter Open Biome, a non-profit organization that provides hospitals with screened, banked frozen stool for administration.

Although barriers to FMTs remain, including a paltry reimbursement, the availability of donor stool is a huge step forward.

The Emergence of Antibiotic Resistance

I am back on the ID consult service so it is bound to be a busy week. 

As I was perusing the NY Times yesterday, I came across this editorial on the rise of antibiotic resistance. The opinion piece highlights the looming crisis in antimicrobial resistance. Noted are the following points:

• Antibiotics are overused, not only by physicians but also in agriculture
• Carbapenem resistance is on the growth- a harbinger of significant resistance across various antibiotic classes
• There is little financial incentive for pharmaceutical companies to develop and market new antibiotic classes

A more detailed report on antibiotic resistance by the World Health Organization can be found here.

I do not mean to sound alarmist but the emergence of antibiotic resistance is the public health threat of the times.

Patient Hand Hygiene at Home Predicts hand Hygiene in the Hospital

Here is a concise communication published in Infection Control and Hospital Epidemiology on hand hygiene. This article has an interesting spin, specifically, that patient hand hygiene at home predicts hand hygiene in the hospital.

Hand hygiene in the hospital decreased compared to that at home, and home practices were strongly associated with hospital practices. So, if patients reported regular hand hygiene at home, they were also more likely to wash their hands in the hospital, albeit less frequently than at home. Being bed bound and being unable to access hand sanitizer may play a role in decreased patient hand hygiene.

If patients are expected to remind staff to wash their hands, they must first believe in hand hygiene, both at home and in the hospital.

Infectious Diseases News Article on Hand Hygiene

We just can't seem to get enough on hand hygiene. Here is a an informative article on hand hygiene in Infectious Diseases News. 

The article is well written and covers areas such as hand hygiene compliance, changing habits, objective monitoring, new hand hygiene technologies, behavioral science and ensuring accountability.

In short, achieving sustained hand hygiene compliance is challenging and requires education, observation, feedback and accountability. 

For some, it really may take a behavior change.

HIV and Coronary Artery DIsease

Source: CDC.gov

Here is a recent publication in the Annals of Internal Medicine that reports the association between HIV infection and coronary artery disease. The bottom line, independent of typical cardiovascular risk factors, HIV positive men, particularly those who are untreated, have accelerated rates of coronary artery disease.

I have a small battalion of HIV positive patients who are very concerned about their health and longevity. Many of these patients, specifically focus on the control of their HIV, the results of their CD4 count, viral load and cholesterol level. Many of these patients, frustratingly, still continue to smoke and are overweight.

As a growing body of evidence implicates HIV infection as a driver of cardiac disease, modifiable risk factors such as cholesterol, obesity and smoking become increasingly more important for risk reduction.

Stop smoking. Change your diet. Lose weight. Exercise.

Contact Precautions- More is Not Necessarily Better

Those who have previously followed my blog are aware that use of contact precautions is controversial. At VCU Medical center, we no longer isolate patients who are infected or colonized with MRSA or VRE.

Here is a recent study assessing the impact of increased contact precautions on compliance with best practices.  As the burden of isolation increased (20% or less to greater than 60%), a decrease in compliance with hand hygiene (43.6%-4.9%) and with all 5 components  (hand hygiene before and after patient encounter, donning of gown and glove upon entering a patient room, and doffing upon exiting)  was observed (31.5%-6.5%). 

To me this underscores the following: we are still looking for the best way to apply contact precautions and for a means to promote and maintain compliance with contact precautions when its use is deemed necessary.