Sometimes the Messenger is as Critical as the Message

The other day I attended a lecture by a highly respected nurse-PhD investigator. The lecture explored the critical impact of nursing on safety and patient centered outcomes. The presentation was backed by robust data and highly relevant references.

The crowd was unmoved (some were bored and walked out), which is a true shame.

I have always felt that an engaged and effective lecturer uses narrative, enthusiasm and passion to move the audience. The messenger can be as important as the message, as summarized in this post.

Opportunity lost for being a change agent.

Automated Teller Machines and Pedestrian Crossing Controls - Not the Next Epicenter for Gram Negative Rods!

Really? Someone actually tested the microbial burden on automated teller machines (ATMs) and pedestrian crossing controls?

The answer is yes and no gram negative rods, including ESBL and CRE organisms were identified. Only gram positive organisms were found as reported in this brief  article published in the Journal of Hospital Infection. 

I understand that ATMs and and pedestrian crosswalk buttons are high touch surfaces, but need we be so germaphobic? Microbes are ubiquitous. What shall we culture (or re-culture) next? All door handles, steering wheels, and poles on subway cars? We already know that cellphones carry a significant bioburden, as summarized here.

I would simply suggest that we practice hand hygiene prior to eating and that we limit touching our eyes, nose and mouth, to the fullest extent possible, with unwashed hands.

Germaphobe I am not!

The Mask of the Red Death, Cholera and a Good Read on Infectious Diseases

It was just the other day that I learned that the short story, The Mask of the Red Death, written by Edgar Allen Poe, was inspired by the events of a society ball held by German poet Heinrich Heine. The ball was held in the midst of the 1832 Paris cholera epidemic which claimed 19,000 lives in total. During the ball, a harlequin dancer felt a chill in his legs and took off his mask, revealing a violaceous face. The chlolera symptoms had begun. By the end of the night, several party goers, along with the harlequin, were dispatched to the famed Hotel-Dieu where they later died of cholera.

For infectious diseases nerds, such as myself, here is a good read titled Pandemic by Sonia Shah. The author explores the emergence of new pathogens and pandemics, including cholera, in both a scholarly and gripping fashion.

Outbreaks do not occur randomly, rather, they are the consequences of expanding urbanization, deforestation, crowding, poor public health infrastructure, misuse of antibiotics and globalized, highly connected travel.

Good read.

Contact Precautions for the Control of Endemic Pathogens: The Ongoing Debate

I will be debating my esteemed colleague, Dr. Dan Morgan (University of Maryland) on the use of contact precautions for the control of endemic MRSA and VRE at the 2016 ID Week National Meeting (October 2016).

The topic is contentious with many, myself included, on the side of not employing contact precautions for the control of endemic MRSA and VRE. A robust and highly reliable horizontal infection prevention program is generally sufficient to control these pathogens, as has been our experience (summarized here). 

More recently, a paper published by colleagues of mine in California, supports our horizontal approach to controlling endemic pathogens, suggesting that elimination of routine contact precautions for MRSA and VRE can be done safely.

Looking forward to the debate.

Hand Hygiene Automated Monitoring Systems- Not Yet Ready for Prime Time

Back in 2009, Dr. Mike Edmond and I studied (probably) the 1st generation hand hygiene sensor technologies and published it in the Journal of Hospital Infection.  This technology sensed alcohol on healthcare worker hands and significantly increased compliance with hand hygiene (>90%). The study was small, involved a single unit with motivated and consented nursing participants. No clinical outcomes were assessed. Real world, sustained applicability was neither attempted nor demonstrated.

Monitoring hand hygiene is not easy and no infallible strategy exists to do so, as summarized here.         

We are once again attempting to implement, assess, and study hand hygiene monitoring technology in our hospital, this time using a stepped wedge trial design. The challenges are many, as very nicely summarized in this recent publication.   Having initially overcome the cost barriers, we are seeing hurdles such as getting front line worker buy-in, accuracy (when compared to the gold standard of direct observation), acceptability of being monitored, minimizing work-flow disruption and engagement of data and feedback. 

Hand hygiene technologies for monitoring compliance may have a significant role in the near future however it is not yet ready for prime time.          

Stethoscope Decontamination- What Works Best?

Last week I did an interview for Medscape on healthcare worker contamination (hands, clothes, instruments) and its impact on potential cross-transmission of pathogens to patients. Although the proportionate impact of apparel and stethoscopes on infections is unknown, it is generally believed that 20%-40% of all hospital acquired infections are due to cross transmission from the inanimate environment.

It is well known that healthcare worker apparel can carry a significant bioburden, as summarized here in this SHEA Expert Guidance paper. Stethoscopes, too, become colonized with pathogens such as MRSA.

Many (myself included) advocate wiping down stethoscopes between cases.This is typically done with alcohol wipes. This recent article in the American Journal of Infection Control suggests that chlorhexidine (CHG) would be a better option for stethoscope disinfection as the residual effect CHG can inhibit stethoscope re-contamination for up to 4 hours. Simple and easy with a potential benefit of enhanced bioburden reduction.

Perhaps it is time for us to rethink our disinfectant of choice for stethoscopes.

Pragmatic Studies and Vancomycin for Recurrent C. difficile Prevention!

I like pragmatic studies, as previously written here.

Here is an article on the efficacy of oral vancomycin for the prevention of recurrent C. difficile. Now this is by no means a slam dunk article in support of oral vancomycin as preventive therapy for patients receiving systemic antibiotics and who have a history of prior C.difficile infection. The authors reported a significant decrease in C. difficile infection in patients receiving prophylaxis (4.2% vs 26.6%).

While this may not be the optimal, prospective, randomized study, a vexing and important clinical problem, the prevention recurrent C. difficile infection, is tackled by assessing existing data via a formal retrospective methodology, a pragmatic solution. Important clinical questions remain such as what is the optimal dose of vancomycin (or another agent, such as fidaxomicin), duration of treatment, and the impact of prophylaxis on the fecal microbiota?

Regardless, this pragmatic study gives us some empiric data to guide our 'real life' management of recurrent C. difficile prevention. 

The use of oral vancomycin to prevent C. difficile recurrence in patients on systemic antibiotics is not just hocus pocus.

Labor Day 2016: Back from Argentina, Back to Work

Back at work after spending the last 10 days in my native Argentina on a family visit.

Those who know me are well aware of my passion for futbol (soccer) so it should be no surprise that I managed to get to a match in, Racing Club (Buenos Aires) vs my hometown team of  Club Atletico Talleres de Cordoba . The day was cold, wet and windy, apt for those who are passionate about football.

Laboring on Labor day, back at it.