Back to the Stacks with a Rare Glimpse of John Huxham's Essay on Fevers

Thank you to Margaret Kidd, library archivist at the VCU Tompkins-McCaw Library for the Health Sciences, for organizing another stellar visit earlier this month to the Special Collections and Archives. Images are below.

In the assortment of rare books and manuscripts viewed on the day, my favorite was John Huxham's Essay on Fevers, an 18th century treatise on infectious diseases (prior the the germ theory of infection). 

Why do I frequent the medical library, particularly in this digital age?

To be inspired and to be given a figurative kick in the academic pants so as to keep researching and publishing. Also, I just like books and cool open spaces. There are worse pastimes. 

This is my last blog posting of 2017. Thank you to the few who regularly follow my blog.

Happy New Year.

Medical College of Virginia, 1844

Medical Archives Collection

John Huxham's Essay on Fevers- 1755

Medical Literary Messenger Fall/Winter 2017/2018 Published! Download the Latest Edition Here.

As Editor in Chief, I am proud to announce that the Fall/Winter 2017/2018 edition of the Medical Literary Messenger has published. 

Please visit the literary magazines's website here, or download the latest edition via this link.

Thank you, always, to my superb collaborators, Brie Dubinsky, Rachel Van Hart and Drs. Mike Stevens and Megan Lemay along with VCU student editors Erica Kim, Sarah Lee and Lisa Olmsted. 

Question the Default! Follow-up Blood Cultures for Gram Negative Rod Bacteremia and Other Matters

Question the default in clinical medicine, especially when the evidence is weak. Just in case we need reminding, within our specialty the majority of our guidelines are based on expert opinion or low quality evidence, as summarized here.

I really enjoyed this article in Clinical Infectious Diseases which suggested that follow up blood cultures on patients with gram negative rod (GNR) bacteremia are generally not needed. Kudos to the authors for attempting to address this in an empirical fashion. 

Certainly follow up blood cultures should not be definitively abandoned for patients with GNR bacteremia (particularly when resistant organisms are in the mix or when clinical response to therapy is not prompt) but we should question their routine value and acknowledge their potential harm (risk of contamination with gram positive skin commensals resulting in more antibiotic exposure). 

Why stop there? Why prescribe 14 days of antibiotics (instead of 5-7 days) for common infections? Why obtain urine cultures on febrile, catheterized patients when the risk of invasive infection from a urinary source is low (urine test stewardship)? Why use contact precautions for endemic MRSA and VRE control in the hospital when the quality of evidence is poor? The list goes on and on.

Question dogma.

Tuskeegee Truth Teller and the Perils of Whistleblowing

Source: The American Scholar

I have veered off topic here as I am not a medical ethicist. The topic is at least tangentially related to infectious diseases, in this case, syphilis.

This article in The American Scholar (Phi Beta Kappa Society) chronicles the action of Peter Buxton, a former US Public Health Employee, who, through patience and persistence, brought to light the infamous Tuskegee Institute syphilis study.

The article underscores the rarity of whistleblowing, both then and now, and highlights the perils of speaking up- across broad and varied disciplines including business, medicine and politics. Honest behavior is not rewarded and is commonly penalized. 

Even with greater awareness and university investigational review boards to ensure ethical standards, the federal research oversight system still has no mechanism for dealing with whistleblower complaints.

Yes, we have made progress in medical ethics. Speaking up for the truth is still challenging and now without consequences.

Book Review and JAMA Letter to the Editor

Photo Credit: Dr. Dan Diekema- HAI Controversies Blog

Thank you to Dr. Dan Diekema of the University of Iowa for this generous review of our textbook on the highly visited HAI Controversies Blog. We (the book editors) appreciate the kind words. Here is a photo from our 'book launch' at ID Week 2017.

Now, for words that were less than enthusiastic on our behalf (with my colleagues Dr. Dan Morgan and Dr. Richard Wenzel) I refer you to this Journal of the American Medical Association (JAMA) letter to the editor that was recently published. Our response follows immediately. The letter to the editor was a counterpoint to our JAMA Viewpoint on contact precautions for endemic pathogens (MRSA and VRE) published in summer 2017

Here is my perspective, again: mandates should be backed by the highest quality evidence possible. Short of high quality evidence, we should strive for pragmatic infection prevention practices that are sustainable and play out in the real world. These practices should match local needs and resources.

I prefer honest, scientific dialogue over dogma.

Dreams of Troy by Dr. Richard Wenzel - Book Signing Today at the MCV Foundation

The Dreams of Troy book signing by our very own Dr. Richard Wenzel took place today at  the MCV Foundation.

Best wishes to Dr. Wenzel on the launch of his new book. The book is available via Barnes and Noble or Amazon.com

Images below.

Futbol for a Cause: 13th Annual Richmond City FC Copa Navidad

The 13th Annual Copa Navidad was held at SCOR - our annual "futbol for a cause" indoor game brings all Richmond City FC members (past and present) together to raise money for a local charity. The Richmond City Blues played the Richmond City Whites in a charity match for bragging rights and for a good cause. The outcome was a draw!

This year's Copa Navidad benefited Richmond Street Soccer, run by Daryl Grove and Taylor Rockwell (two RCFC members). Richmond Street Soccer is the RVA arm of Street Soccer USA, a national nonprofit that uses soccer to combat homelessness and the causes of homelessness.

The Richmond team is partnered with The Healing Place, a substance abuse recovery center where 70% of the graduates remain sober for at least one year and 78% find employment within 90 days of completing the program.

The men who join the Richmond Street Soccer from The Healing Place are working hard to improve their lives. The dedication, team spirit and self-confidence that comes with playing soccer is part of that process. 

For more information visit The Healing Place website at http://caritasva.org/programs/healing-place/ and Street Soccer USA website at http://streetsoccerusa.org/

I have been with Richmond City FC since 2003 and am proud to still mind the goal for one of their teams. More importantly, I am proud to participate in the Copa Navidad.

Images from the event are below.

Richmond Cty FC Copa Navidad 2017

Richmond City FC Old Guard: L to R: The Blogger, Frank Fulco, Andy Marr and Sean Samuel

With Richmond City FC mate- Dr. Frank Fulco

Richmond City FC Christmas Spirit

Antimicrobial Stewardship- The Role of the Patient ?

In 1996 PubMed indexed one paper with the search term "antimicrobial stewardship.' In 2017, 630 papers are indexed under the same search term. Antimicrobial stewardship (AS) is on the rise. This cool article lends a new perspective- that of the role of the patient as an antimicrobial steward.

Really?

Patient centered care is also on the rise and is neatly summarized here in this British Medical Journal article. Patient involvement in AS does not seem so far fetched.

I personally think that rapid PCR diagnostics, particularly for viral respiratory pathogens and diarheal illnesses, should have a sizable impact on unnecessary antibiotic use. A definitive diagnosis mitigates the fear of being wrong and prescribing a 'just in case' antibiotic. This is explored in the film Resistance, as posted here.

Increased patient awareness and understanding of AS and the impact on their care is likely the first step in successfully involving patients in AS endeavors. Patient awareness and advocacy of 'no antibiotics for viruses' almost certainly cannot be a bad thing.

How much impact could this have on AS? 

Nobody knows but it is worth investigating..

Dreams of Troy- Medical Thriller By Our Very Own Richard Wenzel. Book Signing Announcement.

For those in the area,  on December 11, 2017, at the MCV Foundation, our very own Richard Wenzel will be signing his new medical thriller- Dreams of Troy.

The event will be from 3:00 p.m. to 5:00 p.m.   Copies of the book will be for sale at the event. The book may be purchased online via Amazon.com.

Here is a link to the launch of Dr. Wenzel's previous book, Labyrinth of Terror.

Looking forward to seeing everyone there.  Expect images on the blog immediately afterwards.

Approaches to Hand Hygiene Monitoring: From Low to High Technology Approaches.

L-R: Michelle Doll MD, MPH and Nadia Masroor, MPH

Congratulations to my research coordinator, Nadia Masroor, MPH and VCU Associate Hospital Epidemiologist and Assistant Professor, Dr. Michelle Doll, on their recent invited article in the International Journal of Infectious Diseases on hand hygiene monitoring- a perspective covering both low and high technology approaches.

For years we have had a hand hygiene direct observation monitoring program at VCU Health -a  strategy which is common place in North America.  We have begun the deployment of a wireless, blue tooth based hand hygiene technology badge carried by individual healthcare workers (nurses, care partners, residence and attending physicians).  This technology allows us to track hand hygiene - as measured by foam in and foam out of patient rooms at the individual and group level.  As with nearly all hand hygiene monitoring there are inherent limitations-  this does not capture all 5 moments for HH as defined by WHO. So far, two hospital units are near completion of the 1st phase. The house wide deployment will roll out in a step-wedged design over the course the next 18 months.

The volume of data is extraordinary.  Whereas the the hand hygiene monitoring team captured roughly 35,000+ hand hygiene opportunities per year, our technology  has thus far captured > 90,000 in 8 weeks in two units. Dr. Doll and Nadia Masroor are leading the project.

This technology does not represent infection control salvation, and, as with everything, the decision to employ it is subject to an opportunity cost. The new technology, however, will allow us to promote and track hand hygiene more vigorously, a step towards greater reliability in safety.

More to come.

Resistance: Film on the Threat of Resistant Microbes

For any of you seeking an engaging and well done documentary on antimicrobial resistance (suitable for the lay public), check out Resistance.  The film is available on Netflix.

The film neatly summarizes the antibiotic era and the drivers of antibiotic misuse in both medicine and agribusiness. A 'tragedy of the commons' is looming in the threat of a post-antibiotic era.

In medical practice, rapid  infectious diseases (PCR based) diagnostics minimize uncertainty and can curtail the use of unnecessary just-in-case antibiotics. The next frontier is the use of computer assisted decision support- clinical decision trees to maximally guide antibiotic prescription at in real time, as explored here in this recent Clinical Infectious Diseases article.

Antibiotics must be treated as precious resources. 

Primum Non Nocere, But First Length of Stay and Patient Throughput

The central tenet of medicine is primum non nocere, first do no harm. Compelling and resounding but not sufficiently convincing (to some) when it comes to infection prevention prioritization.

All hospitals have infection prevention goals and priorities. After all, preventing hospital acquired infections is primum non nocere on a population level. When coupled with evidence based risk mitigation strategies and an understanding of significant harms, this should be sufficient to drive infection prevention priorities.

Impact on length of stay and patient throughput  (as I previously discussed in a blog) is a critical driver for many decision makers in the hospital. Decreasing length of stay and maximizing throughput is the new Holy Grail of hospital administration, disregard this angle at your own peril if you seek to persuade and prioritize infection prevention strategies across your institution.

Raising Awareness of Antibiotic Resistance- Locally

Although I commonly do media interviews representing VCU on infectious diseases, yesterday was  the first time that I addressed antibiotic resistance on camera.

It am encouraged that awareness of antibiotic resistance and overuse is getting greater local attention. It certainly cannot hurt the cause of antibiotic stewardship. 

The interview and video clip can be accessed here.

What is trending in Infection Control? Seek Diverse Sources for a Greater Perspective

Read on and seek diverse sources......

What is hot infection control and where should you seek information?

This article, which was recently published in Infection Control and Hospital Epidemiology, explores trending topics and information sources in infection prevention. 

As expected, peer-reviewed journals play an important gatekeeping, elite role in the dissemination of knowledge. The material in published journals is not sensationalized, more rigorous, and, in theory, less biased. 

Websites, including advocacy sites, are unfettered from the peer review process and promote views or topics that trigger a more emotive response (i.e deadly superbugs.)

Blogs are a less elite mechanism for publication and information dissemination. These have a role particularly when an academic prospective is employed. Of course, these too can be biased. I strive to make my medical blog as academic as possible within the framework of my own professional perspective (or bias). One of the best infection prevention blogs is the one by my friends and colleagues- Controversies in Hospital Infection Prevention.

So read on my friends and seek diversity in sources.

Happy 90th Birthday-Feliz Cumpleaños Professor Enrique Gerstzen

Happy 90th birthday to Professor Enrique Gerstzen, colleague and argentine compatriot at VCU Medical Center. We should all be so lucky to be thriving and working at 90 years of age. A true living legend.

Feliz cumpleaños (90) al Profesor Enrique Gerstzen, colega y compatriota argentino en el centro médico VCU. Todos debemos ser tan afortunados de estar prosperando y trabajando a los 90 años de edad. Una verdadera leyenda viviente.

Images below. 

3rd Annual Gordon Archer Research Day- In Pictures

Today we hosted the 3rd Annual Gordon Archer Research Day at the VCU Medical Campus. 

The collaborative program highlights research in infectious diseases, allergy/immunology and microbiology. The diversity of topics included transplant infectious diseases, infection prevention, HIV care, global health, antimicrobial stewardship and bench research in microbiology and allergy/immunology. Presentations were at the podium and in poster format.

Thank you to Drs. Larry Schwartz (Allergy/Immunology) and Dennis Ohman (Microbiology) for their enthusiastic support and participation.

A very special thanks, always, to my assistants Krystle Shaw and Peggy Andrews. Without them, none of these projects and programs would be possible.

Images are below.

Dr. Salma Abbas

VCU Infection Prevention Nurses:L-R Amie Patrick and Michele Fleming

Graduate Student Kyle Rodino

Dr. Lawrence Schwartz- Allergy and Immunology Chairman

VCU Medical Student Karthryn Osei-Bonsu

VCU medical student Ian Lovern and VCU Infection Prevention Nurse Ginger Vanhoozer

Pharm D Resident Payal Kakadiya

L-R: Krystle Shaw and PeggyAndrews

With Nadia Masroor, MPH- VCU Infection Prevention Research Coordinator

Poster Session