Friday, June 22, 2018

Contact Precautions in Nursing Homes: Not What You Might Expect!

I like it when studies challenge expectations.

It is generally believed that patients in contact precautions are visited less frequently by healthcare workers.  Not so, as reported in this recent paper on contact precautions and healthcare worker practice across nursing homes in the Veterans Affairs (VA) Healthcare System.  Increased patient contact may be be secondary to a greater need for clinical care by isolated patients.

Sadly, compliance with gowns and gloves for isolation was limited. This was not unexpected as was the global sub-optimal hand hygiene reported.

The clinical impact of contact precautions on endemic pathogens in VA Healthcare System nursing homes? Not reported in this study. To me, that is the million dollar question.

Back to watching the World Cup....

Monday, June 18, 2018

Antebrazos Descubiertos! Editorial Publicado en La Revista Latinoamericana de Infectología Pediátrica

Para los de solo habla inglés, disculpen, que este blog será en español.

He escrito mucho sobre el atuendo médico pero esto es la primera vez que publico un manuscrito basado en este tema en una revista latinoamericana- la Revista Latinoamericana de Infectología Pediátrica.

Así que les paso este link (manuscrito) con mucho orgullo, para que lean sobre el uso de uniforme con antebrazos descubiertos.

Polémico e interesante.

Sunday, June 17, 2018

Congratulations VCU ID! A Proud Night for All.

Drs. Salma Abbas and Barry Rittmann

Dr. Mike Stevens recognizing VCU Global Health Pathway graduating residents

Congratulations to our infectious diseases fellows, Drs. Salma Abbas and Barry Rittmann on their graduation!

Dr. Salma Abbas has finished her  3rd year of training- with a dedicated year in hospital epidemiology and a Master of Public Health degree. Dr. Rittmann completed his clinical fellowship and will continue as a 3rd year hospital epidemiology fellow at VCU.

Special kudos to Dr. Mike Stevens, recognized for his leadership of the VCU Global Health Residency Pathway training and given an Excellence in Teaching award.

The ID Division was also recognized for our distinguished teaching, a testament to our education mission.

Last but not least, a special thank you to our fellowship directors, Drs. Jane Cecil and Jillian Raybould, our ID Associate Chair for Education, Dr. Sangeeta Sastry, and of course the entire ID faculty and staff, without you, our education accomplishments would not  come to fruition.

The VCU Department of Medicine Residency and Graduation Ceremony event was held at the Virginia Science Museum, a proud night for all.

Friday, June 15, 2018

Don't Expect Me To Be Productive. It's World Cup Time!

Argentine Compatriot: Lionel Messi
For anyone concerned about my productivity over the next 4 weeks, please have some understanding and compassion. It is World Cup time and I will be focused on the 64 live matches. I am a man and Argentine so resisting the football (soccer) craze is futile.

I am not the only one struggling with the World Cup vs. work dilemma, as summarized in this article. Work productivity and the World Cup do not mix!

There will be emotional ups and downs all tournament long.  I will have to catch up on work tasks post tournament. However, if my Argentine compatriots take the trophy back to Buenos Aires, it will all be worth it.

Olé, Olé, Olé, The Beautiful Game!

Thursday, June 14, 2018

I Love Bundles and Checklists, Until They Do Not Work!

Source: National Health
Like most hospital epidemiologists, I absolutely love bundles and checklists that standardize risk reduction practices.  These mechanisms help to optimize practice and minimize optionalism.

Unfortunately, sometimes the bundles do not work, as reported in this recently published article.

Kudos to the authors for taking a hard look at ventilator associated pneumonia (VAP) bundle compliance and impact on ventilator associated events (VAE).  Bottom line, the current bundle does little to actually impact VAE. 

Not all VAE are VAP, admittedly. Regardless, we need better protocols that encompass all aspects of ventilator safety-including infections, minimizing pulmonary edema,sedation vacations, extubations etc.

The most eye opening result of the above study: the use of chlorhexidine oral care increased the risk of VAE, a proper challenge to the paradigm of bioburden reduction.

So, once again, I love bundles and checklists until they do not work.  

Time for us to rethink the current VAP/VAE reduction process. We should avoid clinging to failed practices and critically seek new VAE risk reduction mechanisms.

Tuesday, June 12, 2018

What is the Missing Piece of Global Antimicrobial Stewardship? The Environment!

Environmental change is a looming threat and in this case it is not global warming.

In 2017, Lubbert et al published this manuscript describing environmental pollution from  mass drug manufacturing industries in India. Significant concentrations of well-known anti-infectives such as voriconazole, fluconazole and levofloxacin were recovered in the water surrounding these production facilities. Corresponding microbiological analyses revealed a significant concentration of extended-spectrum beta-lactamase and carbapenemase-producing Enterobacteriaceae and non-fermenter bacteria.

To what extent does environmental contamination of water and food supplies with antimicrobial agents drive global antimicrobial resistance?  The answer is not fully known but is neatly explored in this Lancet Infectious Diseases commentary.

Bottom line, as we attempt to get a grasp limiting antimicrobial resistance, our approach must be multi-dimensional. This includes antimicrobial use in both animal and human populations, clinical surveillance mechanisms to monitor resistance patterns, and environmental monitoring. In toto, these elements can better shape and define the policies and practices desperately needed to optimize global antimicrobial stewardship.

Monday, June 4, 2018

Can't Explain! Vexing (Unexplained) Medical Symptoms

Got a feeling inside (can't explain)
It's a certain kind (can't explain)
I feel hot and cold (can't explain)
Yeah, down in my soul, yeah (can't explain)

The Who certainly did not have unexplained medical symptoms in mind when composing their famous hit sing, Can't Explain.

I have been giving this some thought lately given the frequency with which chronic fatigue presents in the general infectious diseases clinic.

This article, published in the Journal of the Royal Society of Medicine (UK),  explores how physicians manage unexplained medical symptoms.  Thirty to fifty percent of symptoms cannot be well explained. Sadly, we are poorly trained to consistently approach these symptoms and engage patients in a meaningful, reassuring way. The result is an encounter which is unsatisfying for both doctor and patient.

All is not doom and gloom. There may be a partial solution, as published here. Targeted, focused teaching on the management of medically unexplained symptoms, over 2-3 hours per year, would be both well received and beneficial.

Can't explain should not mean that we can't reassure.

Tuesday, May 29, 2018

Paradigm Pause: Contact Precautions for MRSA and VRE Causes Less Harm

There is mounting evidence that discontinuing contact precautions for endemic MRSA and VRE infections atop a robust horizontal infection prevention platform does not jeopardize infection rates and may cause less harm.

Elise Martin et al report a significant decrease in non-infectious adverse events after discontinuing contact precautions for MRSA and VRE at UCLA Medical Center.

Using an interrupted time series analysis methodology,  we recently reported no negative impact of discontinuing contact precautions for MRSA and VRE on already decreasing trends of all device associated infections (including MRSA and VRE).

Since we do not perform active surveillance screening, critics claim that we may be negatively impacting the colonization burden. Also, as we do not perform post discharge surveillance of our patients (is that practical?), critics claim that patients colonized at our institution could manifest infection elsewhere. This is possible yet not probable. As VCU Health is the major safety net hospital of central Virginia, it seems unlikely that our patients would seek care at a private, suburban hospital.

The evidence is mounting for a paradigm change, or at least, for a paradigm pause: for us to thoroughly question the efficacy of contact precautions to control endemic MRSA and VRE.

Thursday, May 24, 2018

Storytelling in Medicine: In the Middle of the Night

Today we had a very special Medicine Grand Rounds at VCU Medical Center-where we explored storytelling and narrative in medicine.  

The four invited storytellers included Dr. Megan Lemay, Dr. Pablo Bedoya, Dr. Sam Powell and Dr. Richard Wenzel.

Each shared their experience through patient centered narratives, highlighting important humanistic insights and personal growth. Masterfully done. 

Similar topics explored through medical narratives, reflective writing and art can be found in our Medical Literary Messenger magazine, edited by Dr. Lemay and me.  All content is open access and fully downloadable.

Wednesday, May 23, 2018

Sunday in the Park with Infectious Diseases: Not All Doom and Gloom!

George Seurat: A Sunday Afternoon on the Island of La Grande Jatte

There have been a lot of visits to my last post-Infectious Diseases in Troubled Waters. Fortunately, not all is not doom and gloom!

This clever article , with a reference to Sunday in the Park With George (the musical based on George Seurat's artistic life), published in Journal of Infectious Diseases, highlights multiple infectious diseases career possibilities.

True. Like a blank art canvas with endless possibilities, a career path can be composed in many fashions.

There is a significant and ongoing need for infectious diseases physicians to manage the emergence of multidrug resistant organisms, antimicrobial stewardship programs, and respond to the growing demands of hospital infection prevention programs. Other career options include public health and private practice.

Not so bad, pay equity notwithstanding. 

Monday, May 21, 2018

Infectious Diseases in Troubled Waters

ID Consults in the hospital: long hours, (relatively) low pay
I have been giving this a lot of thought recently, particularly as I battle with my institution's compensation plan to preserve salaries (note: not increase salaries) and set realistic revenue generation (RVU) expectations. 

Infectious diseases is in troubled waters. In many respects, infectious disease clinical practice is a market failure.

It should surprise few people that infectious diseases specialist are some of the lowest paid physicians, as highlighted here.  Our current healthcare system heavily rewards volume of care and procedures.  Many infectious diseases consults are high complexity, low volume.  We do not perform billable procedures.  None of this bodes well for us.

This NEJM Blog on Why Experienced HIV/ID Doctors Leave Clinical Practice- the push for high volume work and the growing demands of the electronic medical record do not help.

Couple the above with competing expectations to supervise learners and publish academic work, morale plummets.

Academic infectious diseases is in jeopardy, as explored here by Drs. Wenzel and Edmond.

Until there is a fundamental change in the US healthcare system such that the primacy of volume and procedures no longer drives reimbursement, and until universities comprehend the limitations of compensation plans for certain specialties, I see no immediate relief in sight.

Wednesday, May 16, 2018

Jersey! Where Community Acquired C. difficile is Extremely Rare


Where the community acquired C. difficile is extremely rare. I am referring to the Channel; Island of Jersey, with only one microbiology lab and a population of <100,000 people, where the majority of C. difficile cases had recent healthcare contact as referenced in this article in Infection Control and Hospital Epidemiology.

This is in contrast to the much cited NEJM article on diverse C. difficile reservoirs. 

In my opinion, the biggest driver of C. difficile is antibiotic (over)use. Antibiotic presciption can have a population based impact on C. difficile rates, as reported here in The Lancet.

Broad formulary restrictions are likely more effective in countries with a National Health Service.  In the USA, absent a well coordinated health system and given the primacy of physician 'autonomy', such an approach would be seen as counter cultural and unacceptable, even if benefits outweigh harms.

Shame on us.

Saturday, May 12, 2018

Congratulations Matt Nottingham and Laura Pedersen! VCU School of Medicine Graduates 2018

Drs. Matt Nottingham and Laura Pedersen

A special congratulations to newly graduated medical students- Dr. Matt Nottingham and Dr. Laura Pedersen.

Both published manuscripts with me and presented posters at the SHEA Spring conference. 

Matt's manuscript on UVC light disinfection is referenced here. Laura's manuscript on hand hygiene in the OR and procedure areas is referenced here.

Dr. Nottingham will train in emergency medicine and Dr. Pedersen will train in internal medicine with us at VCU.

Both have very bright futures in the medical profession.

Thursday, May 10, 2018

Urine Culture Over Testing and Length of Stay: How to Resonate with Hospital Leadership

Unnecessary urine culture testing is a major issue.  Urine test stewardship is en vogue, as I have previously blogged

This paper, recently published in Clinical Infectious Diseases, reports the impact of unnecessary urine cultures on something that is highly relevant to the hospital C suite: length of stay.

Unnecessary urine culture testing results in increased length of stay, likely secondary to excessive treatment.  Increase length of stay negatively impacts patient throughput.  In a volume driven healthcare system, this is what most resonates with administration.

While attempting  to change the culture of urine over testing, make sure to emphasize the impact on length of stay and patient throughput if you seek executive sponsorship and prioritization.

Tuesday, May 8, 2018

Resist Dogma and Question Paradigms! Bacteriostatic vs Bactericidal Antibiotics

I love it when new data emerges that questions dogma and challenges paradigms.

In the book Pandemic, by Sonia Shah, the author explores the danger of paradigms in infectious diseases.Paradigms are theoretical constructs that provide explanatory frameworks for scientific observations. However, paradigms create expectations, which can limit perceptions and result in confirmation bias and change blindness.

This paper, published in Clinical Infectious Diseases, challenges the dogma that bactericidal antibiotics are a better choice than bacteriostatic antibiotics.  The underlying

paradigm is that a 'cidal' antibiotic more effectively kills bacteria and is thus clinically more efficacious.

Not necessarily true.

As masterfully summarized by the authors, a comprehensive review of the literature does not support this conclusion.  Serum and tissue concentrations, along with pharmacodynamics, are likely more important than the bacteriostatic versus bactericidal qualities of the antibiotic.

Resist dogma and question paradigms.

Monday, May 7, 2018

Reducing Surgical Site Infections: From Global to Local.

Two recent article published in Lancet Infectious Diseases are worth noting.

This paper published by the GlobalSurg Collaborative highlights the disparities in surgical site infection (SSI) rates for gastrointestinal surgery across high, middle and low income countries. Low income counties have a disproportionate burden of SSIs, many (36%) with bacteria resistant to perioperative antibiotics.

What can be done?

This manuscript , published in the same edition of Lancet Infectious Diseases, reports the success of a surgical infection prevention bundle in 4 hospitals across 3 African nations. The bundle included perioperative bathing, avoiding hair removal, surgical hand preparation, patient skin preparation, optimal antibiotic prophylaxis and improved operating room discipline (number of people in OR, room entries etc). Compliance with these measures are reported in table 2 of the manuscript.  The bundled intervention resulted in a 60 % SSI reduction across all sites.

At VCU Health, we employ an SSI risk reduction program under the umbrella of Enhanced Recovery After Surgery (ERAS), lead by Dr. Michael Scott, as previously posted on this blog. Following ERAS implementation, our SSI rate in colorectal surgery has significantly decreased and was presented at SHEA Spring 2018 (Portland, Oregon). 

The manuscript is in process so stay tuned.

Wednesday, May 2, 2018

A Global Scourge! Carbapenemase Producing Organisms

Source: CBS news
For anyone seeking an excellent review article on carbepenemase producing organisms (CRE) searchno more!

I direct you to this recently published review in Clinical Infectious Diseases. The article highlights advances in laboratory detection strategies and neatly summarizes treatment strategies with combined antimicrobial therapies.

Evidence based best practices for CRE infection prevention are largely lacking. For example, the optimal duration of contact precautions remains unclear, as summarized here in our SHEA Expert Guidance Paper.

A global scourge, indeed.

Tuesday, May 1, 2018

Thank You Sentara Norfolk General Hospital: Grand Rounds on Infection Prevention

Thank you Sentara Norfolk General hospital for their invitation and generous hospitality. 

Today I delivered Grand Rounds on Infection Prevention: Practices, Processes and Controversies. The lecture was also transmitted via WebEx to 12 Sentara regional hospitals.

Special thank you to Dr. John Brush for his introduction and to Amy Ross, CME Director, for coordinating all aspects of the event.

Lovely spring day in Norfolk, Virginia, with pre-event photos and a post-event, parting view of the bay above.

Monday, April 30, 2018

Join SHEA (Membership Video): Everyone is Doing it!

SHEA 2018 membership promotional video, now on the heels of SHEA Spring 2018!

Join SHEA, everyone is doing it!

Thoughts on C. difficile: Keep it Real

Hospital leadership is understandably concerned about C. difficile rates given its designation as a CMS Hospital Acquired Condition. No one wants to be the negative outlier in public reporting. The pressure is on.

Much of the emphasis on risk reduction was really an emphasis on reducing unnecessary testing and false-positive test results-known as Test Stewardship. This is the low hanging fruit and not truly infection prevention.

The CDC Compendium of Strategies to prevent C. difficile highlights key interventions for risk reduction. This paperrecently published in Clinical Infectious Diseases, used modeling to asses both patient centered and hospital centered interventions and highlights the efficacy of a 2 intervention bundle: daily use of a sporicidal agent and C. difficile screening on admission. Together, the bundles decreased hospital onset C. difficile by 82% and asymptomatic hospital onset colonization by 90%. 

UVC light disinfect also reduces VRE and C. difficile infections as summarized here by Dr. Alexandre Marra and colleagues and by us in this invited review article.

However, diverse sources of C. difficile have been reported, suggesting that most hospital onset cases are not hospital acquired.  Colonization sources are diverse with disease later precipitated by antibiotic use, so the importance of antimicrobial stewardship cannot be overlooked.

We follow the CDC compendium strategies, universally use sporicidal agents for daily and terminal disinfection, deploy UVC Robots, have a robust antimicrobial stewardship program and have recently implemented an EMR based C. difficile PCR decision support to minimize over testing (test stewardship).

As for active detection and isolation of C. difficile, we have yet to pull the trigger. 

The prevention of C. difficile is complicated and multifaceted, not like the more linear approach taken for the prevention of device associated infections (CLABSI, CAUTI, VAP etc), where the presence of the invasive device is the driving risk factor.

We need acknowledge the limitations to better understand the outcomes of C. difficile prevention. 

Keep it real.

Tuesday, April 24, 2018

Hospital Acquired Infections: How Much Is Preventable and How Hard Should We Try?

Back from Society for Healthcare Epidemiology (SHEA) Spring 2018.

Thank you for the generous comments, tweets and feedback on my SHEA lecture titled Hospital Acquired Infections: How Much Is Preventable and How Hard Should We Try?  Too kind.

So how much can we prevent and how hard should we try?

Hospital acquired infections (HAIs) result in significant morbidity, mortality and cost- obligating us to act. 

The soundbite of "getting to zero" was initially explored here by my colleague Mike Edmond. Infection prevention science is inexact. Even high quality studies have limitations, infection prevention processes are inconsistently implemented and practices can can be controversial (contact precautions for endemic pathogens). Further, diagnostic strategies (test stewardship) and gaming can lead to inexact HAI incidence and false conclusions about preventability. Human beings are chaotic systems and do not always respond to linear interventions.

Perhaps up to 75% of HAIs are potentially preventable when focusing on modifiable by risk factors. 

We should relentlessly strive to minimize ‘potentially preventable’ HAIs as this is consistent with the Hippocratic oath of primum non nocere.

We should seek practical (satisfice) solutions for the real world with reliable implementation of known risk reduction interventions. In doing so we must leverage information technology to assist with HAI surveillance/prevention and advocate for sound process measures and reporting policies. Implementation science must be prioritized. HAI strategy decisions should be evidence driven and based on cost/benefit as much as feasible.

Last, we must be clear on expected HAI outcomes- specify what we can and cannot control. 

Don't oversell yet aim for zero potentially preventable infections.

Friday, April 20, 2018

SHEA 2018- Portland, Oregon: In Pictures

Thank you to the Society for Healthcare Epidemiology of America for organizing a very high quality conference- SHEA Spring 2018.

Kudos to my VCU Team for their excellent work and scientific presentations. You make me very proud!

Images from the last several days are below.

laura Pedersen

Heather Albert, RN

Jacob Pierce, MD

Pamela Bailey, DO

Ginger Van Hoozer, RN

Barry Rittmann, MD

Salma Abbas, MD

With Drs. Mike Stevens and Michelle Doll

Dr. Michelle Doll

Dr. Michelle Doll

Dr. Mike Stevens moderates a session on infection prevention in low and middle income countries