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.

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.

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 here. C.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?

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

Doc Vader Goes to Hospital Administration

This short video is very much tongue in cheek with an ounce or two of truthful comedy.

Enjoy.

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.

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.

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.

'Street Cred' and Medical Leadership: It is Not Trivial

I just recently reviewed a paper for PLoS One, a systematic and comprehensive review of medical leadership in hospital settings. I truly hope that the paper sees the light of day and is published. Of course the paper highlighted the personal and context specific features of medical leaders, none of which were really different to leadership in non-medical settings. However, the authors highlighted that medical leadership differs from general leadership most crucially in the quality and perception of credibility- clinical credibility. Without it, the ability to persuade, influence and role model is diminished.

I have previously explored the importance of physician leaders maintaining a clinical practice.

Clinical 'street cred' is a necessary (yet not sufficient) ingredient for successful physician leaders. 

Talk the talk and walk the walk. The rest is noise.