Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in Healthy Individuals- We May not Want to Know

What do we do with healthy individuals who are fecally colonized with extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae? Recently, it was reported that nearly 15% of healthy patients are ESBL colonized.

Some are already advocating active detection (screening) and isolation of patients who are ESBL colonized.

This is reminiscent of MRSA active detection and isolation argument and of the 'look before you leap' issue, previously articulated by my colleagues Drs. Michael Edmond and Dan Diekema in this article.

Bottom line, there are too many unknown variables regarding ESBL active detection and isolation. What is the real risk of invasive disease in healthy patients with ESBL colonization? What is the risk to others? How long does colonization last? How do we decolonize such patients (and no, fecal transplants for decolonization do not seem feasible)? What sort of cost and labor will screening entail to front line providers and hospital laboratories? What impact will this have on patient throughput?

Last, many of us are reconsidering contact precautions for endemic pathogens, as summarized here. Thus, what incremental benefit, atop a robust horizontal infection control program,  will contact precautions add to the control of ESBL in endemic settings?

Too many questions, too few answers.

We need to be thoughtful and not reactionary with respect to ESBL control in the healthcare setting.

Lord Byron's Lameness

When one combines literature (or people of literary significance) with medicine, I am generally interested.

Here is a cool article on Lord Byron's lameness, published in Pharos.

Lord Byron likely suffered from a clubbed right foot. This was both an embarrassment and personal weakness which he attempted to conceal to the fullest. Treatment consisted of painful forced manipulations. Special boots were custom made for  the poet to disguise rather than correct the deformity.

Most notably, it is argued, Byron's drive to excel physically (particularly in swimming), his extreme dieting, alcohol abuse and womanizing were compensations for his physical disability.

Physical deformity possibly driving the ambition of a great poet. 

Fascinating medical history.

Do No Harm! Infection Prevention

Here is an article in Vox (no relationship to Vox Medica) that nicely summarizes a critical juncture in current hospital infection prevention. 

We need to truly approach all hospital acquired infections (HAIs), in this instance central line associated bloodstream infections (CLABSIs) as ‘airplane crashes’, meaning that we investigate what went wrong and engineer mechanisms to ensure high reliability performance of infection prevention best practices. 

This is where we have headed with formal drill down tools for all HAIs at VCU Health, regular checklist audits, performance feedback and accountability. 

I am not claiming that the current science of infection prevention can prevent all HAIs. We are, however, responsible for prioritizing and reliably implementing, with documentation, infection prevention best practices. 

Anything less falls way short of a true culture of safety.

Clean Hands Save Lives Documentary

Above is the trailer of the documentary Clean Hands. I have not yet been able to find the full film to view, so, if  you know of how to access it in North America, please pass on the information.

Here is the film's website at Clean Hands Save Lives.org

What Do You Do With the Infectious Diseases Physician Who is Noncompliant With Antimicrobial Stewardship Program Guidelines?

What do you do when the infectious diseases physician is noncompliant with antimicrobial stewardship program guidelines?

Dealing with it is not easy, as discussed, here.

I personally fancy the peer-to peer comparison, demonstrating how the physician in question is a true outlier. I find that this works when comparing surgeon to surgeon surgical site infections data or unit to unit comparisons of infection prevention process and outcome measures. No one likes to look 'bad' amongst peers or wants to be seen as that guy.

Inviting the outlier infectious diseases physician into the antibiotic stewardship management process, as part of the 'team', may also lead to a practice change.

Last, administrative controls may be required, i.e. a letter or suspension coming from upper level management. In my mind this is the nuclear option and takes an administration with resolve.

Faces of Prevention: Recognizing Infection Prevention Best Practices

To feedback infection prevention outcomes, we have historically utilized posters (among other methods of communication) in employee only areas. 

Along with process and outcome related data,the new posters now highlight infection prevention best practices in action, either by a well recognized surgeon, the unit specific Champions of Health System Infection Prevention (CHIPs) or a unit secretary. All are part of the infection prevention team.

The images are also present across the 1000+ hospital terminals as screen saving net-presenters. 

Recognize relentlessly, reward and reinforce, to scale.

Our processes and outcomes continue to improve.

Hand Hygiene in the OR: No Slam Dunk!

Sometimes we have to admit our limitations. We hold hand hygiene sacrosanct but knowledge and outcome gaps exist.

Here is a critically important article on hand hygiene in the OR published recently in Infection Control and Hospital Epidemiology.

In this randomized, prospective trial using a hand hygiene technology to capture hand hygiene decontamination events (HDE), despite an 8 fold  increase in HDE, no improvement in hospital acquired infections outcomes were documented, including surgical site infections. The study was methodologically sound.

Despite the 8 fold increase in hand hygiene, perhaps the HDEs were not the 'right' ones, at the most critical times, such as during induction and emergence of anesthesia. This, however, may be a stretch.

The simple fact is we have yet to prove that heightened hand hygiene in the OR improves outcomes.

With growing pressure to improve safety and reduce hospital acquired infections, we should focus our efforts on high reliability performance of wide scale interventions with the greatest known benefits: safety checklists, central line checklists, hand hygiene in non-OR settings, formalized daily review of urinary catheter use, automatic 72 hour urinary catheter discontinuation orders and chlorhexidine patient bathing, to name a few.

Press on.

Infection Prevention Best Practices in Obstetrics and Gynecology. Congratulations Jackie Arquiette.

Kudos to former VCU medical student and former VCU Global Health and Health Disparities Honduras program participant Dr. Jackie Arquiette (now a resident in obstetrics and gynecology at Duke University) on this recent publication on infection prevention best practices in OB/GYN. 

Dr. Arquiette explored perceptions and barriers to infection prevention efforts in a university OB/GYN service highlighting the need for an ongoing curriculum for hand hygiene, staphylococcal decolonization, glove use, operative patient skin preparation and OR attire. 

Ongoing assessment and feedback of infection prevention practice is essential for sustained improvement. 

Zika Virus VCU News Facebook Live Chat

See the interview here.

Pokeman No! Keep This Away From Patient Care Areas.

Call me old fashioned, however, I feel that when performing highly skilled and important tasks, such as flying an airplane or taking care of  patients in a hospital, we should minimize distractions to the fullest extent possible. "Multi-tasking" is not the way to go.

I was less than pleased with a resident the other day who was running Pokemon Go on his smart phone in the ICU. I noticed this when giving him directions on an infectious disease consult.

Here is a recent article on the dangers of smartphones in the ICUs, distractibility is one of them. More recently,  Massachusetts General Hospital sent out a mass mail requesting that staff refrain from playing this game while in the hospital, summarized in this Forbes article (Thanks to Dr. Mike Stevens for forwarding it to me).

We need to be present and attentive when caring for patients.

Pokemon Go, and other smartphone games, have no business in a patient care setting.