The Bedside Nurse, Antimicrobial Stewardship and Infection Prevention

This is an intriguing read in Clinical Infectious Diseases, one that recognizes the role of he staff nurse in antimicrobial stewardship. As stated in the paper, nurses are antibiotic first responders, central communicators, coordinators of care, as well as 24-hour monitors of patient status, safety, and response to antibiotic therapy-  their role as antimicrobial stewards seems self evident. 

Why stop there?

In essence, nursing staff are the champions of infection prevention. Nurses have the greatest contact with patients, almost uniformly wash their hands more than physicians and are major drivers of infection prevention best practices including central line checklists, urinary catheter discontinuation, head of bed elevation, and chlorhexidine patient bathing, to name a few.

Without nursing involvement, patient safety falters.

Back in the United Kingdom

Back in the UK for the week where I was able to visit both London and Cardiff, Wales. Cardiff was particularly sentimental as I was a university exchange student there in 1992.

Old times revisited.

Grenadiers at the Tower of London

Tower Bridge

Tower of London

The London Eye

View of Parliament

Trafalgar Square

Regent Sounds Studio- where David Bowie and the Rolling Stones recorded some of their earliest music

Beau Brummell statue on Jermyn Street

View of the Thames from the Millennium Bridge

Globe Theatre

Norman Keep, Cardiff Castle

Cardiff Castle 

Norman Keep, Cardiff Castle

Cardiff Castle

View of Cardiff from atop Cardiff Castle

Cardiff University- University of Wales

Cardiff, Wales- Bay Area

Cardiff University- my old dormitory hall

Cardiff University grounds as seen from atop of the Student Union

Ramons- famous greasy spoon in Cardiff ,Wales- frequented by University students, also a site where Dr. Who was filmed

Cardiff University Student Union

The Votes are in and Sanitation is the Winner!

With Drs. Mason and Stevens in Honduras,
installing water filters for safe drinking water

The votes are in, as summarize in this BMJ Press release. Sanitation was voted the the greatest medical milestone since 1840, beating out other major achievements such as antibiotics, vaccines and anesthesia.

Here is a related article published recently in BMJ, a meta-analysis of water sanitation studies, confirming the impact  on decreasing protozoal diarrheal infections.

This is consistent with the ongoing, longitudinal public health sanitation works that we coordinate in rural Honduras, as summarized on our VCU Global Health and Health Disparities website.

Loimologia: The Great Plague- A Historical Perspective

The Great Plague makes for some interesting reading. If you are so inclined and have an interest in the a free digital download of Loimologia, or, an Historical Account of the Plague in London in 1665, With Precautionary Directions against the like Contagion, a treatise by Dr. Nathaniel Hodges is available as a free PDF download here (326 pages) via Harvard University. The book was originally published in 1672.

This is no boring tome, rather it is a striking account with detailed observations, clinical assessments and theories on the plague, its origins, treatments and consequences.

Clinical cases are reported along with the theory of disease and contagion (miasmas). Of note are the written accounts of looting and plundering of homes left abandoned by deceased plague victims and departed family members. I was intrigued by the diatribe on  'charlatans' and other 'quacks'  for the probable increased harm caused by their unconventional remedies.  

Here is an another intriguing read , albeit much less lengthy, published by the BBC on the sleepy English village of Eyam which played an important role during the plague years of the 17th century. 

Fascinating. Read on.

A Hard Look at C.difficile- To What Degree Can it Be Prevented?

I have been giving some thought as of late to the vexing issue of C. difficile associated diarrhea (CDAD). To what degree can CDAD be prevented?

Unlike other hospital acquired infections,  such as  catheter associated urinary tract infections, central line associated bloodsteam infections and surgical site infections where the estimated impact of bundled interventions have been well studied (neatly summarized here), CDAD is a different beast. It is epidemiologically much more complex a matter.

Here is some background:

• A significant proportion of the population (up to 20%) is asymptomatically colonized with C.difficile and colonization is much more common than infection.
• There is no mechanism for identifying and treating / decolonizing asymptomatic carriers
• The only infection prevention strategy for asymptomatic carriers is universal gloving and gowning, hospital wide. This is likely not feasible.
• Alcohol based hand rubs, the preferred agents for hand hygiene, may be inferior to soap and water for hand hygiene

The cited interventions for preventing cross transmission of C.difficile are hand hygiene with soap and water, room cleaning with sporicidal agent, terminal enhanced cleaning with UV C light emitting technologies, contact precautions with a lab based alert system to heighten early recognition, antimicrobial stewardship and universal gown and glove.

Even with the above, many cases are not preventable as asymptomatic, colonized patients are not targeted by current infection prevention strategies and are likely a major reservoir of C.difficile.

No studies exist to confirm the expected, proportionate reduction in CDAD with the above bundled interventions (summarized here).

The prevention of CDAD continues to vex us. We are fooling ourselves if we feel that the current infection prevention practices will significant impact CDAD rates in the hospital.

Preventing CAUTIs- Still Looking for the Magic Fix

There is no single best way to prevent catheter associated urinary tract infections (CAUTIs) with the exception of not using urinary catheters. Admittedly, urinary catheters are overused, however, some people actually need them and are thus at risk for a CAUTI.

Strategies such as standardized catheter insertion and automatic electronic medical record generated stop orders reduce risk and limit unnecessary catheter use. Silver impregnated catheters limit bioburden and also reduce risk but are not salvation from urinary colonization and infection.

This recent article published in The Lancet Infectious Diseases evaluated body surface decolonization with chlorhexidine bathing on bacteriuria and CAUTIs in a cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The number of patients assessed was impressive (122,646). Universal decolonization of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin  decreased candiduria and bacteriuria yet not infection in men only. This is no slam dunk.

The authors note that decreasing urinary colonization may have the secondary impact of decreasing unnecessary antibiotic use. This has yet to be proven but is tantalizing.

Again, we are still looking for new and improved strategies to prevent CAUTIs. The magic fix has yet to materialize.

Medical Literary Messenger- Updated in ePub Format

We are proud to report that the Medical Literary Messenger is now available in a variety of formats, made nimble for maximal portability on various devices.

Our site has been updated such that readers can now select a PDF, MOBI, or EPUB for all issues of the MLM. 

Download all issues, in your desired format, here.

Curbstone Diagnosis Costs Nothing, Usually Worth Just as Much

I came across this article, published in the Toledo Blade in 1957. The titles refers to an off the cuff, curbside diagnosis, made by a physician with partial knowledge of the case, misdiagnosing pancreatic cancer with referred pain to the hip as arthritis.

This dated yet still very relevant article is a good reminder of the potential pitfalls of the curbside consult, a frequent occurrence in many medical centers.

Quite simply, with partial information and without a proper assessment of the patient, these consults of convenience may lead to both incorrect clinical questions and answers and may be potentially harmful. They also can be time consuming, particularly if the curbside consults are aplenty, as summarized in this journal article.

I say it over and over to our infectious diseases trainees, curbside consult only with the highest caution and be mindful of the potential pitfalls.