The Hawthorne Effect, The Real Rate of Hand Hygiene and What Happens Next?

We have had a hand hygiene observation program for years now. On a given week, our hand hygiene adherence is 80% to 90%, by direct observation. But what is the real hand hygiene (foam in / foam out) compliance? 

First, it is fair to acknowledge that there is no single best way or standard for observing hand hygiene, as we summarize here.

Having said that, it is also fair to say that when we change our hand hygiene observers so that they pass unrecognized for a short period, hand hygiene adherence drops by 10%-15%. This is the Hawthorne Effect, simply, a change in behavior due to a subject's awareness of being observed. 

Here is an excellent, recent article on the Hawthorne Effect, published in Infection Control and Hospital Epidemiology. Four important features of the Hawthorne Effect are summarized:

• The Hawthorne Effect follow a time dependent curve
• Behavior changes occur after participants become aware of being watched
• The Hawthorne Effect has performance ceiling
• The performance impact attributable to the Hawthorne Effect wanes with continued observation past peak performance

We are interested in challenging current hand hygiene tracking and monitoring paradigms. Can hand hygiene best practices be promoted and sustained with electronic reminder and monitoring technologies, particularly when done to scale? What will be the staff acceptability and what will be the impact, using a house wide, stepped wedge design roll out, on hand hygiene (performance ceiling, sustainability) and patient centered outcomes across wards and ICUs?

Hand hygiene technologies are limited as they can only (at present) measure foam in/foam out and not all 5 WHO moments for hand hygiene. Regardless, if the implementation of hand hygiene reminder and monitoring technologies is done to scale and sustained, we may learn a lot about engineering a lasting behavior change so as to ultimately have a measure of our real hand hygiene practice.

Stay tuned.

Medical Literary Messenger Fall 2015 Published!

The Fall 2015 Medical Literary Messenger has published!

Download it here.

Staphylococcal Colonization and Bacteremia- Not Equal Opportunity

Methicillin-resistant Staphylococcus aureus (MRSA) is not an equal opportunity pathogen. This intriguing article published in Clinical Infectious Diseases highlights gender differences in MRSA bacteremia.

MRSA carriage and bloodstream infection (BSI) shows a male predominance, Males are more prone to bacterial sepsis, but some studies suggest females may have a poorer prognosis from MRSA BSI. 

Why? 

Per the authors, hand-hygiene behavior varies according to gender. Males are less compliant, which in turn may predispose them to higher colonization and infection rates. Nose picking may also have a male gender predilection.  Female hormones such as estrogen affect the expression of virulence factors in Pseudomonas aeruginosa. This may also apply to S. aureus. The reasons are not all that clear.

I am not sure how this translates into new prevention or treatment strategies for MRSA bacteremia. Perhaps specialized hand hygiene campaigns can focus on at risk groups (men)?  Treatment for MRSA bacteremia is likely not to be tailored to gender without more convincing clinical data.

The purported gender differences in MRSA colonization and bacteremia, albeit interesting, may not lend themselves to practical interventions.

 Vexing.

Kicking for a Cause- 11th Annual Richmond City FC Copa Navidad

It is that time of year again, to kick for a cause.

The 11th Annual Richmond City FC Copa Navidad (Christmas Cup) took place today.

All proceeds, along with a matching contribution will be donated to the Fan Free Clinic.

Feliz Navidad!

RCFC- Blue

RCFC Maroon

RCFC Sky Blue

RCFC 2015 Copa Navidad

RCFC Senior (Old) Guard- L to R: Jaye Lewis, Andy Marr, me, Christian Falyar, Frank Fulco and Sean Samuel

Running Revisited- Impact on Health

I was having breakfast the other day in the VCU Faculty lounge perusing an issue of the Mayo Clinic Proceedings. 

This review on the effects of running on cardiovascular disease and mortality is quite informative. As many of us know, running decreases cardiovascular risk, stroke and lowers blood pressure. But running also decreases osteoarthritis of the knee and hip.

Most importantly, the positive benefits of running are seen with reasonable effort. In other words, one need not run excessive distances to receive benefit. Twenty-five minutes of running, several times per week, will likely suffice.

Off to my morning jog!

Cold and Flu Season Inquiries- Back to Common Sense stuff

It seems like I am receiving more than the usual number of inquiries this year on the common cold and influenza.

For the cold, there is no certain prevention or remedy. No antibiotics either.Quit smoking too.

Here is a recent NPR radio interview.

Antibiotic Resistance on Surgery and Cancer chemotherapy Antibiotic Prophylaxis in the USA

What is the impact of declining antibiotic susceptibility on antibiotic prophylaxis in surgery and cancer chemotherapy? Here is  paper recently published on that subject in Lancet Infectious Diseases by my colleague Dan Morgan from the University of Maryland.

The authors estimated that between 39% and 51% of pathogens causing surgical site infections (SSIs) and 27% of pathogens causing infections after chemotherapy are resistant to standard prophylactic antibiotics in the USA.

This is a problem and we definitely need more data to systematically assess the efficacy of antibiotic prophylaxis. Further, we need timely guidance on how best to modify prophylaxis based on the evolving landscape of antimicrobial resistance.

As part of SSI tracking, health system epidemiology teams should critically assess the antibiograms of all SSI isolates to better understand the local prophylactic drug-bug mismatch. This should include assessment of mupirocin and chlorhexidine resistance when staphylococcal decolonization is attempted pre-operatively.

This is precisely our strategy at VCU Health.

Cold and Flu Season Revisited- Media Interview and VCU Health Twitter Chat.

I appears that there is a resurgent interest in cold and flu season, at least locally in Richmond, VA.

Here is a link to the local CBS 6 news interview on influenza.

On November 24, 2015, I participated in a VCU Health Twitter Chat on cold and flu season, accessible here.

I am frequently asked how best to stay healthy and to avoid getting "colds." 

For many, the answer is simple and obvious. 

Stop smoking!

1st Annual VCU Gordon Archer Infectious Diseases, Microbiology and Immunology Research Day

Today we inaugurated the 1st Annual Gordon Archer Infectious Diseases, Microbiology and Immunology Research Day, in honor of renowned researcher Dr. Gordon Archer, now Professor Emeritus at Virginia Commonwealth University.

The idea of having a dedicated, integrated research day arouse only several months ago. With the support of the VCU Department of Medicine and the Dean of the VCU School of Medicine, along with my colleagues in Allergy/Immunology (Dr. Larry Schwartz)  and Microbiology (Dr. Dennis Ohman), we were able to pull it off.  

A special thanks and kudos to my administrative assistants, Peggy Andrews and Krystle Shaw, for doing the hard part, actually organizing the event from start to finish. Invaluable.

The ultimate goal was to learn from each other and to develop new collaborations. 
Mission accomplished.

Below are images from the event along with the roster of presentations.

Dr. Archer is recognized by Dean Strauss

Plenary Session

Plenary Session- Dr. Sean Evans

Plenary Session- Dr. Rebecca Martin

Poster Session

Poster Session

Award plaque for Dr. Archer

Plenary Session- Dr. Amy Pakyz

With Peggy Andrews, Krystle Shaw and Nadia Masroor

VCU Division of ID Administrative Staff (L to R) - Peggy Andrews and Krystle Shaw

Presentations and Posters- 2015:

8:00-8:45 AM- Breakfast

8:45- 8:55 AM- Dean Strauss recognizing Dr. Gordon Archer

8:55- 9:00 AM Opening Comments by Dr. Gonzalo Bearman

9:00- 10:20 AM- 4 Presentations, 20 minutes each

• Amy Pakyz, PharmD. – “Impact of High-risk Medication Usage on Healthcare facility-onset C. difficile Infection”
• Gail Christie (PI, Microbiology-Immunology)- The Prp protease – a novel target for antibiotic development in S. aureus and other Gram-positive pathogens
• Lawrence Schwartz- “Tryptase and its ongoing story”
• Yoshi Fukuoka (Lawrence Schwartz)-" Effects of the angiotensin and bradykinin pathways on human mast cells."

10:20- 10:40 AM- Break

10:40 AM-12:00 PM- 4 Presentations, 20 minutes each

• Michelle Doll, M.D. (Gonzalo Bearman/Mike Stevens)– “PPE training perceptions/beliefs”
• Sean Evans (Carlyon Lab, Microbology-Immunology)- “The obligate intracellular pathogen, Orientia tsutsugamushi, modulates NF-κB via secreted effectors, Ank1 and Ank6”
• Rebecca Martin (Conrad Lab, Microbiology-Immuno) – “Is helminth-induced B1 IgE protective against allergic disease?”
• Greg Buck (PI, Microbiology-Immuno) – Overview of microbiome projects and the technologies available.

12:00-1:00 PM- Lunch/ Posters 

1:00-2:20 PM- 4 Presentations, 20 minutes each

• Anne Masich, PharmD. Candidate 2016 (Patricia Fulco) –  “Retrovirus and Opportunistic Infections”
• Betty A. Forbes, PhD, D(ABMM) & Christopher D. Doern, PhD - “Using Mass Spectrometry to Define the Clinical Significance of Alloscardovia omnicolens”
• Mike McVoy- “Cytomegalovirus shed in urine is insensitive to antibody neutralization”
• Sahar Lotfi-Emran (Lawrence Schwartz)- “Interferon gamma enhances mast cell ability to activate CD4+ T cell response to cytomegalovirus”

2:20-2:45 PM- Break

2:45- 4:05 PM- 4 Presentations, 20 minutes each

• Nadia Masroor, Project Coordinator (Gonzalo Bearman/Mike Stevens) – “HH Technologies”
• Dan Nixon, Director, VCU HIV/AIDS Center – “Effects of Statins on Biomarkers of Inflammation and Immune Activation in Virologically Suppressed Individuals with HIV”
• Brant Ward (Lawrence Schwartz)- “Antigen uptake and processing by human mast cells, a new paradigm”
• Dan Markley (Michael Stevens/Gonzalo Bearman)- “A Survey to Inform and Optimize the Design of an Antimicrobial Stewardship & Infectious Disease Smartphone App at an Academic Medical Center”

4:05- 4:15 PM- Conclusion 

Posters in Infectious Diseases:

• Laura Pederson (Gonzalo Bearman/Mike Stevens) – “Hand Hygiene in the OR” & “Endoscopy Procedure Suites”
• Nadia Masroor (Gonzalo Bearman/Mike Stevens) – “The Association of Climate Temperature and Bare Below Elbow Compliance”
• Matt Nottingham (Gonzalo Bearman/Mike Stevens)- “UV-C Light as a Means of Disinfecting the Anesthesia Workstation”

• Salma Abbas Muhammad (Michael Stevens/Gonzalo Bearman) - Station-Based Honduras Outreach Trip Education Project.
• Jason Cook (Michael Stevens/Gonzalo Bearman) - Impact of Chlorination of a Gravity Operated Water Distribution System on Clinical Incidence of Diarrhea and Fecal Contamination in Rural Honduras
• Nathaniel Warner (Michael Stevens/Gonzalo Bearman)- “Investigating the Impact of Dengue and Chikungunya in a Rural Population in Yoro, Honduras”
• Jennifer Dinnel (Michael Stevens/Gonzalo Bearman) - "Barriers to Breast Cancer Screening in Paraiso, Dominican Republic
• Meghan Kaumaya (Michael Stevens/Gonzalo Bearman) - Cervical Cancer Screening in Developing Regions: Observations from Paraiso, an Underserved Community in the Dominican Republic
• Nehal Naik (Michael Stevens/Gonzalo Bearman) - Knowledge and Attitudes about Soil-Transmitted Helminth Infection Risk in Rural Honduras
• Soumya Murag (Michael Stevens/Gonzalo Bearman) - Dengue and Chikungunya Virus in the Dominican Republic: Knowledge, Awareness and Preventative Practices
• Lucas Potter (Michael Stevens/Gonzalo Bearman) - Biosand Filter for Use in Decentralized Water Treatment.” 
• Kristina Kelly (Michael Stevens/Gonzalo Bearman) - Rainwater Catchment and Purification System for Rural Honduras
• Anita Molayi (Michael Stevens/Gonzalo Bearman) - The Effectiveness of Antimicrobial Restriction: Trends in Usage of Restricted and Unrestricted Gram-Positive Antimicrobial Agents at VCU Medical Center
• Dan Markley (Michael Stevens/Gonzalo Bearman) - "Designing the Ultimate Antibiotic App: Results of a Survey at An Academic Medical Center"
• Dan Markley (Michael Stevens//Gonzalo Bearman)- “Deploying a Novel Metric to Contextualize Overuse of Carbapenems at an Academic Tertiary Care Hospital”

Poster Presentations from Microbiology & Immunology:

• Katie R. Bradwell, Vladimir Lee, Andrey Matveyev, Myrna Serrano, and Gregory Buck (Buck Lab, Micro-Immunol). “Genome Architecture of Trypanosoma cruzi.”
• Preethi Iyengar, Myrna Serrano, Andrey Matveyev, Vishal Koparde, and Gregory Buck (Buck Lab, Micro-Immunol). The trypanosomatid mitochondrial genomes and the evolution of RNA editing in the order Kinetoplastida.
• Katie R. Bradwell, Vishal N. Koparde, Andrey V. Matveyev, Myrna G. Serrano, João M. P. Alves, Bernice Huang, Hardik Parikh, and Gregory A. Buck. “Comparative Genomics of Trypanosoma conorhini, T. rangeli, and T. cruzi.”
• Bernice Huang, Myrna Serrano, Vishal Koparde, and Gregory A. Buck (Buck Lab, Micro-Immunol). “Evolution of Trypanosoma cruzi and the Bat trypanosomes.”
• Niels Asmussen, Anita Marinelli, Myrna Serrano, Hardik Parikh, Bernice Huang, Nihar Sheth, Kim Jefferson, Jennifer Fettweis, the Vaginal Microbiome Consortium, and Gregory Buck (Buck Lab, Micro-Immunol). “Gardnerella vaginalis Types and Their Role in Vaginal Health.”
• Aminat Oki (Carlyon Lab, Micro-Immunol) - “Developing a system to efficiently transform obligate intracellular bacteria”
• Kathryn Hebert (Carlyon Lab, Micro-Immunol) - “Anaplasma marginale Outer Membrane Protein A-Receptor Interactions”
• Cheisea Cockburn (Carlyon Lab, Micro-Immunol) - “[endif]Anaplasma phagocytophilum Parasitizes Host Sphingolipids for Completion of its Replication Cycle”
• Andrea Beyer and Ryan Green (Carlyon Lab, Micro-Immunol) - “Orientia tsutsugamushi Ank9 interacts with COPB2 to Co-opt Host Cell Retrograde Traffic”
• Kyle Rodino (Carlyon Lab, Micro-Immunol) - “Pathogen induced host cell ER stress benefits the intracellular bacterium, Orientia tsutsugamushi”
• Sheela Damle (Conrad Lab, Micro-Immunol) - "The role of ADAM10 on dendritic cells in allergic disease"
• Joe Lownik (Conrad Lab, Micro-Immunol) -The importance of adam10 and adam17 on immune regulation
• Devin Cash (Cornelissen Lab, Micro-Immunol) - Transferrin-iron utilization in Neisseria gonorrhoeae as a possible target for treatment and prevention of gonorrhea. 
• Abigail L. Glascock, the Vaginal Microbiome Consortium and Jennifer M. Fettweis (Fetweis Lab, Micro-Immunol), Clinical and Genomic Characterization of Two Vaginal Megasphaera Species
• Nicole R Jimenez, the Vaginal Microbiome Consortium, and Jennifer M Fettweis (Fetweis Lab, Micro-Immunol), Characterization of Bifidobacterium breve Strains in the Vaginal Microbiome 
• Hien Dang*, Dylan N. David*, Suryanaren Kummarapurugu*, Abigail L. Glascock, Sarah K. Rozycki, Nicole R. Jimenez, Alan Alves, Jennifer M. Fettweis (Fetweis Lab, Micro-Immunol) - Isolation, Identification and Analysis of Lactobacillus and Bifidobacterium from the Human Vaginal Microbiome (*Equal contribution).
• Naren GK, Daniel Contaifer, Dayanjan S. Wijesinghe and Kimberly Jefferson (Jefferson Lab, Micro-Immunol) - "Role of Staphylococcus aureus lipases in delaying wound healing”
• Ayana Scott-Elliston (Lee Lab, Obstetrics Gyn & Micro-Immunol) - "Determination of HLA-C and KIR gene association to preeclampsia."
• Eun Lee (PI, Obstetrics Gyn & Micro-Immunol) - “Expression of ERAP2 Variant plus HLA-C in trophoblast Cells Activates Immune Response and Increases CD3-CD69+ cells.”
• Hussein Aqbi (Manjili Lab, Micro-Immunol) - “Treatment-induced tumor dormancy”
• Jerilyn Izac (Marconi Lab, Micro-Immunol) – Title TBA.
• Lee Oliver (Marconi Lab, Micro-Immunol) – Title TBA.
• Mike McVoy (PI, Pediatircs / Micro-Immunol)- “A Vaxfectin®-formulated DNA Vaccine Induces Antibodies that Block Cytomegalovirus Entry into Fibroblasts and Epithelial Cells”
• Eliezer Diaz (Ohman Lab, Micro-Immunol) - “Discovering a novel way to inhibit alginate production in Pseudomonas aeruginosa via a drug screen of a chemical library.”
• Jing Yang (Zhou Lab, Micro-Immunol) -”Taurocholate Induces Cyclooxygenase-2 Expression via the Sphingosine 1-phosphate Receptor 2 in a Human Cholangiocarcinoma Cell Line”
• Mike Hinton (Zhou Lab, Micro-Immunol) - “Alcohol Potentiates HIV protease inhibitor-induced ER stress and hepatic lipotoxicity”
• Jing Yang (Zhou Lab, Micro-Immunol) -”Taurocholate Induces Cyclooxygenase-2 Expression via the Sphingosine 1-phosphate Receptor 2 in a Human Cholangiocarcinoma Cell Line”
• Mike Hinton (Zhou Lab, Micro-Immunol) - “Alcohol Potentiates HIV protease inhibitor-induced ER stress and hepatic lipotoxicity”

We Continue to Debate the Use of the White Coat in Inpatient Settings

Source: Boston Globe

We  continue to debate the use of the hallowed white coat in inpatient settings. Most people who know me are well aware of my opinion on the matter. 

Here is an article in the Boston Globe where both Miked Edmond and I are interviewed on bare below the elbows, something which we started at VCU Medical Center. Our monthly compliance with bare below the elbows for inpatient care is between 70-80%.

Without a mandate, we have made bare below the elbows for inpatient care normative behavior, part of our broad based, horizontal infection program which rigorously promotes infection prevention best practices and minimizes bioburden in the inanimate environment. The bare below the elbows component was highlighted in the VCU School of Medicine Magazine, 12th and Marshall.

Back to the Boston Globe article, to reproduce the closing quote by Dr. Neil Fishman, from the University of  Pennsylvania: “I’m just left scratching my head, trying to figure out why some really bright people who I respect have latched onto this issue.” 

Really?

Fecal Patina in the OR- Dr. Silvia Munoz-Price at VCU Combined Anesthesia and Surgery Grand Rounds- November 12, 2015

It was standing room only at the VCU Kontos Medical  Sciences Building for Dr. Silvia Munoz-Price's lecture on the Fecal Patina in the Operating Room. The lecture is largely based on the editorial published in 2015 in Anesthesia and Analgesia.

The OR environment and anesthesia work areas are teeming with pathogens which can lead to IV line stopcock colonization and likely heighten the risk of bloodstream infections and surgical site infections.

Bioburden reduction in the OR is a looming challenge for decreasing surgical site infection risk. 

More to come.

The Common Cold vs. Influenza- Q&A for VCU News

Here is the link to a brief Q & A that I recently did for VCU News.

By no means was this a comprehensive review on the matter. I am frequently asked about measures to decrease the risk of getting ' a cold' or 'the flu.' Much of it come down to simple common sense. Get enough rest, alcohol in moderation, wash your hands and, for many, quit smoking! Last, an influenza vaccine is also a good idea to limit the risk of influenza.

Simple, common sense measures that go a long way to preventing respiratory viral infections.

Hospital Room Disinfection- Many Unanswered Questions

I spent much of this rainy Saturday in my home office reading and listening to vinyl records. 

I fortuitously came across this excellent publication, a thorough review on cleaning hospital surfaces to prevent health care associated infections. 

This may be a surprise to some, but we have no slam dunk evidence to confirm that hospital room surface disinfection directly results in decreased health care associated infections. Comparative effectiveness studies with patient centered outcomes (health care associated infections) are exceedingly uncommon. To make matters even more unsettling, there is no clear definition of how to assess cleanliness or even how to best define a 'clean' hospital room.

The corresponding commentary to this article highlights a point which really makes sense to me. Although we clamor for heightened daily and terminal room disinfection, environmental service workers are frequently a marginalized part of the health care staff. 

We need to recognize and appreciate environmental service workers as critical and valued members of the healthcare team. Train them, compensate them fairly, and celebrate their work. Without their valued service, attempts to attain 'cleanliness' in the environment will fall short of expectations.

Predictors of Yoga Use in the USA

Okay, admittedly, this is not even remotely relate to infectious diseases, my specialty. Also, the findings of this study , the purpose of which was to investigate the prevalence, patterns, and predictors of yoga use in the U.S. general population, were largely predictable, but I could not resist as the title caught my eye.

Using cross-sectional data from the 2012 National Health Interview Survey Family Core, Sample Adult Core, and Adult Complementary and Alternative Medicine questionnaires (N=34,525), frequencies for lifetime and 12-month prevalence of yoga use and patterns of yoga practice were analyzed. Using logistic regression analyses, sociodemographic predictors of lifetime yoga use were analyzed. 

Lifetime yoga practitioners were more likely female, younger, non-Hispanic white, college educated, higher earners, living in the West, and of better health status. Among those who had practiced in the past 12 months, 51.2% attended yoga classes, 89.9% used breathing exercises, and 54.9% used meditation. Yoga was practiced for general wellness or disease prevention (78.4%), to improve energy (66.1%), or to improve immune function (49.7%). Back pain (19.7%), stress (6.4%), and arthritis (6.4%) were the main specific health problems for which people practiced yoga.

In the USA, Yoga is largely practiced by young, affluent, educated white women with an interest in health and wellness, not necessarily those most in need of its potential benefits. Empiric evidence to confirm what was already suspected.

Urine Sample Collection from Urinary Catheters- Less Than Stellar Practice

In my opinion, it is bad enough that Foley (urinary)  catheters are overused and that urinalysis and urine cultures are ordered indiscriminately with little understanding of how to  interpret the results. To further complicate matters, urine samples on catheterized patients are frequently collected in a suboptimal fashion, as suggested by this article recently published in the American Journal of Infection Control.

In this  study, 76% of nurses surveyed reported receiving education on catheter associated UTI  (CAUTI) risk reduction within the last 12 months. Strikingly, 327 (83%) of all nurses surveyed reported that they never collect urine samples by draining directly from the drainage bag, yet only 58% viewed others to be fully compliant with that standard.

Improperly collected urine sample  will lead to incorrect diagnostic and management decisions.

The overuse of urinary catheters is rampant. Besides ongoing education on urinary catheter use, the effect of which dissipates typically in 6 months, automated mechanisms for daily review and automatic discontinuation orders to limit catheter use are the most consistent and evidence based mechanisms to minimize CAUTIs.

It is to remove the urinary catheters in a consistent and formalized approach.

BIG-LoVE: Respiratory Viruses Uncovered!

The BIG- LoVE  study (Utah- Better Identification of Germs-Longitudinal Viral Epidemiology)- kudos for the catchy acronym, rather clever indeed, especially from a state (Utah) with a prior history of polygamy.

The article can be accessed here and was published in Clinical Infectious Diseases. 

The investigators assessed the viral etiology of respiratory illness by prospectively collecting weekly symptom diaries and nasal swabs for PCR analysis from families for 1 year, analyzed data by reported symptoms, virus, age, and family composition, and  evaluated the duration of virus detection.

Twenty-six households (108 individuals) provided concurrent symptom and nasal swab data for 4166 person-weeks. 

Participants reported symptoms in 23% and a virus was detected in 26% of person-weeks. There were 783 viral detection episodes; 440 (56%) associated with symptoms. Coronaviruses, human metapneumovirus, and influenza A. Viral detections were usually symptomatic; bocavirus and rhinovirus detections were often asymptomatic. The mean duration of PCR detection was ≤2 weeks for all viruses and detections of ≥3 weeks occurred in 16% of episodes. Younger children had longer durations of PCR detection.

So viral detection is common and often asymptomatic. Again, we need to resist using anti-infectives when not warranted. If it is not Influenza- no oseltamavir. Also, if the the clinical presentation is of a viral upper respiratory infection, no antibiotics!

Eventually we will need better diagnostics, one that can detect pathogens and the concomitant inflammatory response, to differentiate between infection versus asymptomatic shedding.

Donning and Doffing Personal Protective Equipment- Dr. Michelle Doll Interview and Podcast

Her are two media highlights on our recent JAMA Internal Medicine commentary, first authored by Dr. Michelle Doll.

The first was published in Reuters, accessible here.

The next, a podcast featuring Dr. Curtis Donskey and VCU's Dr. Michelle Doll, is accessible here.

Click here for the my blog entry on the invited commentary.

Risky Business- Removal of Personal Protective Equipment

Removal of personal protective equipment (PPE) can be risky business as highlighted in this hot off the press article in JAMA Internal Medicine. 

When assessed for the appropriate removal of PPE (gowns and gloves), over  40% of HCWs contaminated themselves through poor technique.

We wrote the accompanying commentary to this article, accessible here. Dr.Michelle Doll elegantly argues in favor of selective use of contact precautions, with improved PPE, calling for enhanced mechanisms of training, evaluation and feedback of healthcare worker donning and doffing of gloves and gowns. To be effective, this must be done to scale, across the hospital environment. 

This is our charge and we moving forward. 

More to come.

It All Comes Down to Implementation!

It all comes down to implementation! 

Those at VCU know that I have been saying this over and over and over, sounding much like a broken record.


Chlorhexidine patient bathing only works if done correctly, as summarized in this paper. The authors utilized a calorimetric assessment tool to assess chlorhexidine concentrations on patient skin following a chlorhexidine bath. The intervention was education of nursing and patients along with monitoring and feedback of bathing performance. Detection of chlorhexidine on patient skin went from a baseline of 46% to 88% following the intervention.

Perhaps there are easier ways to measure completion of chlorhexidine bathing in hospitalized patients. Considerations include product consumption analyses and assessment of bathing documentation in the electronic medical record. These methodologies unfortunately do not measure detectable chlorhexidine concentrations in the skin. Challenging.

It all comes down to implementation.

2015 ID Week- Images from San Diego

I have spent a very busy week in San Diego, at the 2015 ID Week Conference. 

Highlights include meetings and project planning with my colleagues from the SHEA Guidelines committee, presenting a poster and attending some truly superb scientific presentations, including a pro/con debate on bare below the elbows as an infection prevention recommendation. 

The VCU Alumni dinner was also a high point.

Back to Richmond soon.

City View- San Diego

Poster Presentation

Protesters: 'IDSA Lyme Guidelines=Medical Neglect"

Debate question

Debate Response

Sepsis Video: Get Your Sepsy on!

We need not confine ourselves to boring, tedious, online slides sets and modules for our ongoing medical education.

See the video below from Kern Medical Center. Raising sepsis awareness, hammering home critical concepts and management points.

Creative, choreographed, clever.

"Get your Sepsy on"

Soil Transmitted Helminths in Honduras- Internal Medicine Grand Rounds: Dr. Ana Sanchez

Today we had the honor of hosting Ana Sanchez, PhD at VCU's Medical Grand Rounds.

Dr. Ana Sanchez was invited on the Behalf of the VCU GlobalHealth and Health Disparities Program (GH2DP) - Honduras Program. Dr. Sanchez has collaborated with VCU GH2DP on reducing the burden of soil transmitted helminths in rural Honduran populations. The lecture also covered the immunologic and health impact of helminthic infections in resource poor settings.

We were honored to have her visit VCU and to share both her research and our collaborative experience in a Medical Grand Rounds format.

Here is the VCU News article  on the event.

Phenomenal lecture, excellent turnout.

With Drs. Sanchez and Stevens

The Human Microbial Cloud- Infection Prevention Issue?

This intriguing article was recently forwarded to me.

It is generally accepted that the dissemination of microbes between humans and the inanimate environment can occur through direct contact with surfaces or through airborne release. This last mechanism is very poorly understood. 

The investigative team used 16S rRNA gene sequencing to characterize the airborne bacterial contribution of a single persons sitting in a sanitized custom experimental climate chamber. This was compared to air sampled in an adjacent, identical, unoccupied chamber (control room) as well as supply and exhaust air sources. 

Next, and this is where things really get clever, the microbial burden in settled particles surrounding each occupant was assessed and characterized. 

The results suggests that we shed particles and bacteria in our own distinct and unique way, almost like a bacterial fingerprint. Basically, an occupied space is different microbiologically from an unoccupied space and each participant had their own, distinct microbial cloud.

To me this underscores the dynamic yet still poorly understood mechanism in which we interact with the inanimate environment. Although the bacteria isolated were largely not pathogenic, we certainly cannot exclude that patients colonized or infected with a pathogen will not emit their own 'pathogenic' microbial cloud. The extent to which microbial clouds drive hospital acquired infections is largely unknown.

Until we know better, it may still come down to acknowledging that the inanimate environment is a potential reservoir of hospital pathogens and to employing common sense infection prevention mechanisms to minimize bioburden, such as washing our hands, chlorhexidine bathing patients and performing robust daily and terminal disinfection of hospital rooms.

UCI World Road Championships in Richmond, VA: At VCU Health

It is not often that the UCI Road World Championships are in the USA, let alone 50 feet in front of the VCU Health Infectious Diseases Clinic.

Below are a couple of snaps from yearly today.

Whoosh.

View from exam room- VCU ID Clinic, Broad Street, Richmond, VA

Lead riders turning the corner at Governor's Hill and Broad Street, Richmond, VA

Sprint to the finish line- Broad Street,  Richmond, VA

Front of the peloton,  Broad Street, Richmond, VA

The peloton arrives, Broad Street, Richmond, VA