Thursday, August 17, 2017

Medical Literary Messenger Spring / Summer 2017- Published!

As Editor in Chief of the Medical Literary Messenger I am proud to announce that the Summer / Spring Edition has published. This edition includes our first ever photoessay, featuring the VCU Global Health and Health Disparities Program in Honduras. Kudos to all MLM associate editors and contributors.

The publication can be downloaded as a PDF (click here) or as an EPUB/MOBI (here).

All prior editions are available on the archives section of MLM website.

Tuesday, August 15, 2017

Amazing vs. Hired!

I was reading the highly academic Moderate Drummer magazine the other day and came across this referenced cartoon. There is a lot of truth in it.

Having great technique ( 'chops' in drumming parlance) is wonderful but is useless unless you can play consistently and keep time with a band. Drummers who can keep time are generally hired for the gig!

I have seen something similar play out in other spheres.  I have known many knowledgeable and book smart physicians who are less than adept at applying the knowledge at the bedside.  I have also known many footballers (soccer players) with great skill and technique who cannot play a 90 minute match with a team.

Skill, technique and knowledge are absolutely necessary, yet not sufficient.  Application is key. 

If you have both then you are the real deal.                   

Tuesday, August 8, 2017

Test Stewardship and C. difficile: Vexing to No End

Test stewardship is an evolving topic in the medical literature. I recently wrote about test stewardship with respect to urine cultures and CAUTI rates.

Now, as reported here, computerized clinical decision support tools in the EMR can assist in reducing inappropriate C. difficile. Given that nucleic acid amplification tests can be overly sensitive and that C. difficile is part of the normal bowel flora, we are still looking for the 'right test at the right time' to make the diagnosis. A magic 'diagnostic' bullet of sorts.

In the above referenced paper, C. difficile test stewardship decreased inappropriate C. difficile testing, specifically, not testing patients with diarrhea while on laxatives. No significant harm was reported.  This is not salvation but at least a step forward in not over diagnosing hospital onset C.difficile. So I say, press on with such interventions (which we are doing at VCU).

Clostridium difficile infections in the hospital continue to vex us, largely because the extent to which they are preventable is highly debatable, as explored here.  

With the current state of science, solving our C. difficile problem is much like solving world inequality.

Sunday, August 6, 2017

Sepsis Antibiotic Protocols: Potential Downstream Effects

Sir Alexander Fleming
"The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism."  Thus were the words of Sir. Alexander Fleming, the discoverer of penicillin.

We have a potential tragedy of the commons with antibiotics. The consequences extend beyond the growth of antibiotic resistance. The implementation of an electronic sepsis initiative to standardize and maximize antibiotic use for sepsis cases resulted in increased hospital onset C. difficile, as reported here in AJIC. Not surprisingly, the protocol resulted in increased broad spectrum antibiotic use.

Protocols and standardization generally improve patient safety (central line checklists, surgical times outs) but the process is not foolproof. 

We need to monitor and formally study unintended consequences so as to be nimble, pragmatic and modify our infection prevention strategies. 

I am now back from my native Argentina and back to the grind.

Sunday, July 30, 2017

Futbol Argentine Style: Club Atlético Talleres

To 99.99% of readers, this will have no importance. 

I spent yesterday behind the curtains at the training ground of Club Atlético Talleres, of the Argentine Premier Division, where I watched a pre-season scrimmage, checked out the trophy cabinet and took a look around.


Friday, July 28, 2017

Santiago Ramon y Cajal: Maxims in Medicine

Dr. Santiago Ramón y Cajal

I am back home in Córdoba, Argentina. I live on Avenida Ramón y Cajal, named after Santiago Ramón y Cajal, the Nobel Prize winning Spanish Physician.  

Over the last several days I read his book Reglas y Consejos Sobre Investigación Científica, published in1898, wherein he summarizes his observations and perspectives on medicine and scientific investigation. Many of the observations ring true even today: discovery is not necessarily a function of special talent, but a function of hard work, which creates talent, and, low achievement is less commonly from a lack of time and resources, it is more from a lack of willpower. Timeless maxims.

This reminded me of a similar yet more up to date article titled Simone's Maxims (full length article available via hyperlink). 

I strongly encourage anyone in academic medicine to give it a read.

Tuesday, July 25, 2017

On the Argentine: Random Images from Buenos Aires

I am now back in my native Córdoba, Argentina, by way of a one day pit stop in Buenos Aires. 

Below are a few random images from Buenos Aires, including the Recoleta Cemetery and El Gran Ateneo book store, know as one of the best bookstores in the world, as highlighted in the Guardian UK. I picked up some choice new books.

Also, La Biela confiteria, former meeting place of argentine writers such as Jorge Luis Borges and Adolfo Bioy-Casares.

Un día perfecto.

Saturday, July 22, 2017

The VRE Train! Gowns and Gloves Not Required

VRE Train! Gowns and gloves not required

Hashing it Out! Program Planning.

I visited SHEA headquarters in Arlington, VA earlier this week, where I had the honor of participating in the 2018 SHEA Spring Annual Meeting planning committee. 

Really looking forward to the event, some exciting and controversial topics made the final program cut.

At the Amtrak station on the way back home to Richmond, I nearly (and aptly) hopped on the VRE Train (Virginia Railway Express), where gowns and gloves are not required, just how I like it.

Sunday, July 16, 2017

When Having An Infectious Disease Was Fashionable And Socially Acceptable

While perusing the latest issue of the Lancet Infectious Disease I learned of an event titled Fashionable Diseases, which took place at the Edinburgh International Science Festival (April 2017). A Scottish news article on the event can be found here.

Yes, there was a time when having syphilis and even tuberculosis was trendy and even socially acceptable.Gout was seen as glorious, a reflection of affluence. Still, double standards abounded. Syphilis in men was a marker of sexual prowess. In women, sexually transmitted diseases were associated with prostitution and low morals. 

Although modern times are different (we now understand disease transmission and have treatments), some infectious diseases are still viewed through a societal lens. Lyme disease (Borrelia burgdorferi) and Syphilis (Treponema palladium) are both spirochetal diseases. Both have various phases of infection: early infection then later manifestations. Both are fully treatable with antibiotics.  Lyme disease is more commonly seen in Caucasian, upper middle class populations with tick exposures. Lyme advocacy groups are well rooted in the USA. The same cannot be said for syphilis, which is definitely not a socially acceptable spirochetal disease.

Although not seen as fashionable anymore, infectious diseases still evoke varied sympathies.

Tuesday, July 11, 2017

Something Has Been Changed In My Life: The Talking Heads, MALDI-TOF and Central Line Bloodstream Infections

David Byrne of the Talking Heads: Give Me Back My Name
I have been radio silent the last several days. The VCU ID consult service has been high volume!     

I am proud to have published this concise article with colleagues from Philadelphia and Dr. Chris Doern of Virginia Commonwealth University, my home institution. Bottom line, our report explores the potential impact that mass spectrometry (MALDI-TOF) can have on CDC defined central-line associated bloodstream infections (CLABSI). With MALDI-TOF, previously classified skin commensals can now be identified as pathogens thus meeting the CDC criteria for a reportable CLABSI.

What is the scope of the problem? Unknown thus far. With increased use of MALDI-TOF, the issue may be burgeoning. The CDC may need to reassess the CLABSI definition and its surveillance associated master organism list.

Thanks to Dr. Dan Diekema for a cool blog post on the article, with an associated Talking Heads song (Give me back my name, something has been changed in my life - lyrics here). 

One my favorite bands.  I have the LP spinning on my turntable as I type this blog post.

Friday, July 7, 2017

She Blinded Me With Science! Creativity, Non-Conformity and Moving Ideas Forward

Although not my favorite musical artist, I do respect the vision and creativity of Thomas Dolby (of She Blinded Me With Science songwriting fame). His perspective on stimulating creativity can be seen below in this short TED video.

To quote Mr. Dolby, to really be creative " throw away that crutch and work outside of your comfort zone." Try something new, feel the buzz of excitement.

This reminded me of a book that I recently read, Originals, by Adam Grant, wherein he explores how non-conformists move the world. The TED talk by Adam Grant can be found here. I particularly like the concept of being a tempered radical, toning down an idea so as to allow it to take root and flourish. This is a form of pragmatism, something I fancy. In our experience, without an element of tempered radicalism and pragmatism we would never have convinced our hospital administration to discontinue the use of contact precautions for MRSA and VRE. Other concepts highlighted in Originals include questioning the default, exploring multiple ideas while accepting that most will fail, obtaining critical feedback and even procrastinating strategically (so as to let things simmer and mature).

These principles are universally applicable, even in a seemingly less creative field as infectious diseases. Ideas and strategies are the drivers of improved health and outcomes. To that I say challenge existing paradigms if the evidence supporting them is weak. Try new things yet do no harm.  Ask why or why not? Many ideas may not pay dividends in the end. If so, no worries, move on to something else.

Most importantly, surround yourself with talented people and encourage them to explore new perspectives and strategies. In the end the output of the team will exceed the sum of the individual parts. 

Wednesday, July 5, 2017

Reflections on Gowns, Gloves and the Endemic Threshold

I apologize for a longer than usual blog post today.

I have been giving some thought to comments relevant to my work posted on the HAI Controversies Blog. First, I would like to say that the comments are welcomed and drive discussion and debate. I love it.

With respect to the BUGG study and universal gloving, I am not dismissive of personal protective equipment (PPE). As posted in the comment section by one reader, the way that PPE is used probably is important. In this vein, we feel that healthcare workers should be trained for competency in the use of gowns and gloves, as published here. However, we struggle to take make the training effective to scale- across 7000+ healthcare workers in our institution. This would have to be done in a sustained fashion, particularly as employment status changes across personnel. No easy task.

I am frequently asked about a threshold for instituting or discontinuing contact precautions for endemic pathogens such as VRE and MRSA. This is explored in a recent blog post by Dr. Perencevich. I have no endemic threshold (infection or colonization pressure) in mind. Before making a change in infection prevention strategy it is important to understand your institutional trend in all device associated infections, surgical site infections and MRSA and VRE infections.  One must also have confidence in the reliability, as judged by aggressive, standardized audit and feedback, of a horizontal infection prevention platform. With consistently decreasing device associated infections/surgical site infections (CDC definition), decreasing MRSA and VRE infections and a reliable, horizontal infection prevention platform, we discontinued contact precautions for MRSA and VRE in our institution in 2013. The infection rates continue to decline and we have observed no increase in patient harm. We are not alone in this approach, as summarized here.

I realize that the above may not satisfy the calls for high level methodology, however, cluster randomized trials to answer the above 'endemic threshold' question for contact precautions may never materialize. 

Should new data contradict our experience or should infection rates increase, regardless of pathogen, it would be time to critically reassess all elements of our infection prevention program. Everything would then be back on the table.

If I am labelled as biased then that bias is pragmatism.

Tuesday, July 4, 2017

Antibiotic Overuse: A Tragedy of the Commons and the Challenge of Physician Autonomy

Antibiotic overuse is tragedy of the commons, whereby over-prescribing a shared good, antibiotics, reduces therapeutic efficacy as a result of antibiotic resistance. 

Silverman and colleagues recently reported that 46% of patients from an ambulatory cohort were prescribed broad spectrum antibiotics for acute, upper respiratory infections, which are almost always viral in etiology. Mid - or late-career physicians, physicians with high patient volume and practitioners trained outside of the USA or Canada were more likely to write a prescription for an upper respiratory infection.

Outpatient antimicrobial stewardship programs along with financial incentives and peer-comparison approaches may curb excessive antibiotic prescribing. This likely works best for physicians practicing under the umbrella of a healthcare system or a university hospital where there is oversight by antimicrobial stewardship programs. What about the rest of them?

Approximately 33% of US physicians work independently. The website of my state's medical society explicitly states that "No one knows the medical needs of your patients better than you." 

Physician autonomy and independence are powerful forces in the USA. Curbing unnecessary antibiotics and imposing antimicrobial stewardship programs against this tide is no small task.

Monday, July 3, 2017

Do I Make Myself Clear?

For those who greatly appreciate clear and direct writing I highly recommend the book Do I Make Myself Clear? by Sir Harold Evans. 

In a world obsessed with Tweeting and where filtering of content occurs less and less, writing well matters more than ever.

Wednesday, June 28, 2017

Good Enough! Seeking Solutions in the Infection Prevention World

I have heard criticism that our perspective on contact precautions, particularly the discontinuation of contact precautions for MRSA and VRE, is based on scant evidence and is thus not valid. To date, there is little data to support or reject the efficacy of contact precautions for the control of endemic MRSA and VRE, as we published in this thorough review.

It is important not to become fixated on a paradigm so as to lose our ability to question and shift perspective. We should also avoid methodolatry (the profane worship of clinic trials as the only valid trial of investigation).

In the absence of high quality evidence and when high quality, multi-center, cluster-randomized trials to assess the efficacy of contact precautions for endemic MRSA and VRE will likely never materialize (no one will fund it), we must be pragmatic and search for solutions that satisfice in the real world, ones that are good enough.

I believe in primum non-nocere and pragmatism. If discontinuing contact precautions for endemic MRSA and VRE is coupled with a high reliability, horizontal infection prevention program and no increase/declining MRSA, VRE and hospital acquired infections (no harm), then a shift in practice is not unreasonable.

Contact precautions for the control of MRSA and VRE should not be dogmatic and should be used based on institutional assessment and need.

Monday, June 26, 2017

Contact Precautions for endemic MRSA and VRE: Time to Retire the Legal Mandates.

We feel that it is time to retire the legal mandates for using contact precautions for the control of endemic MRSA and VRE in the hospital, which we just published today in Journal of the American Medical Association (with my colleagues Drs. Dan Morgan and Richard Wenzel). The article is free and available full text online.

Contact precautions for the control of these endemic pathogens should be used selectively as guided by local need and not by mandate,  after a high reliability, horizontal infection prevention program has been implemented.

We welcome the ongoing debate.

Tuesday, June 20, 2017

C. difficile as a Hospital Acquired Condition: Time to Give it a Rest

As is well known, C. difficile infection is classified as a CMS Hospital Acquired Condition (HAC). 

The current state of infection prevention science can likely prevent 55-70% of device associated infections and surgical site infections, as cited hereC.difficile is different. Although a compendium of strategies to reduce C.difficile in the hospital was recently published by my colleagues at SHEA, the extent to which hospital acquired C.difficile is truly preventable is unknown and highly debatable.

First, the paradigm that most C. difficile is hospital acquired was challenged by the New England Journal of Medicine article by Eyre et al, demonstrating that diverse reservoirs of C. difficile exist outside of the hospital setting, likely contributing to the rise in current cases.

Recently, our Swiss colleagues demonstrated that to C. difficile can be controlled without the use of contact precautions, an intervention which is held as sacrosanct by many.
Even more recently, it was reported that heightened disinfection had no impact on hospital acquired C. difficile. Aggressive antibiotic(fluoroquinolone) restriction may be the way to go, however, this is not salvation.

These are troubling times in infection prevention as paradigms are challenged.

Until we have a better understanding of the extent to which C.difficile is both acquired and reliably prevented in the hospital, CMS should not penalize healthcare systems for C.difficile HAC measures.

How can we fairly penalize what we cannot (yet) reliably prevent?

Sunday, June 18, 2017

Congratulations VCU Infectious Diseases Fellows: Graduation Day

Congratulations VCU Infectious Diseases Fellowship graduates Drs. Salma Abbas and Scott Anderson, who received their training certificates last evening at a party in their honor. Also, congratulations to Dr. Dan Markley who finished the third year fellowship in infection prevention and who was recently awarded a Master of Public Health degree.

Dr. Abbas will remain with us as a third year fellow in hospital epidemiology and will complete a Master of Public Health degree. Dr. Anderson will return to Louisiana to practice infectious diseases and Dr. Markley will join us as an Assistant Professor of Medicine and epidemiologist at the McGuire Veterans Administration Hospital.

Below are a few images from the event.

Drs. Salma Abbas and Scott Anderson

With Dr. Jane Cecil- VCU ID Fellowship Director

VCU ID Faculty and Fellows

Thursday, June 15, 2017

Tuesday, June 13, 2017

Procalcitonin Use in the Real World: Like the Difference Between a Rock Music Studio Recording and a Live Performance

The Who: Rock is Dead! Long Live Rock!
The use of procalcitonin in the real world is much like the difference between rock music recorded in the studio versus a live performance. Studio recordings can be heavily produced, with multiple tracks, special effects and dub-overs. Live performances are more organic, spontaneous and sound different, sometimes not quite like the original track. Only the really talented can do both well.

I really like this recent article on the real world use of procalcitonin in critically ill patients, published in Clinical Infectious Diseases. The article is an important reminder of the differences between randomized controlled trials and real world implementation. Although randomized controlled trials support the use of procalcitonin for improved antibiotic use, the implementation of procalcitonin in non-study settings is poorly structured, inconsistent and not associated with antibiotic use improvements or clinical benefits.

This underscores the importance of per protocol fidelity for the reproducibility of results.

When implementing an evidence based infection prevention intervention, the key question is as follows: will the strategy (modeled on studies supporting the intervention) play out in the real world, and, can it be done to scale with fidelity? 

If not, do not bother.

Monday, June 12, 2017

Chronic Antibiotic Suppression of Infected Cardiovascular Devices: Data from the Real World

Kudos to this group from the Mayo Clinic for publishing this paper on the outcomes of patients receiving chronic antibiotic suppression for infected implantable cardiovascular electronic devices. This is a real world clinical problem, and requires a real world analysis, one that may not be optimal but that may just satisfice.

Much of what we do is based on little evidence and many knowledge gaps exist.  Many clinical questions simply cannot be answered by randomized, prospective, blinded trials.  I mean, what industry or government agency would pay for a prospective, randomized trial of chronic antibiotic suppression for implantable devices? 

There is no academic glory, by way of grant prestige, in studying this or other vexing, non-research fundable clinical questions.  

Well done.

Friday, June 9, 2017

Meandering in Upstate New York: Random Images

I am away off topic here, but, I took several days away from the office and set off on a road trip to Upstate New York (Syracuse).  The drive up and back (500 miles each way) was an adventure on the back country roads in a two seated roadster.  As the traffic dissipated, the humming engine and the open road fostered a present mindedness that was devoid of daily distractions.  A proper driving experience for a driving enthusiast.

Below are some images from my former hometown of Oneida, NY, just east of Syracuse. The  images include the music store where I brought my 1st drum kit in 1983 (picked up some new drum sticks there the other day, too),  homes from my former neighborhood and various other random stops including the local newspaper where I got my first job (in 1983) and Oneida lake.

Back to work next week, with more appropriate blog material to come.