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

Tuesday, April 17, 2018

The Hospital Epidemiologist. What's in a Name?

What's in a name, or in this case, a title? How does one define a hospital epidemiologist? We discussed this today at the SHEA Board meeting.

The following is my interpretation and does not reflect the official view of SHEA.

Hospital Epidemiologist are Doctors who Prevent Infection! This is done through:

  • Leadership
  • Policy
  • Science and research
  • Preparedness
  • Antibiotic stewardship
SHEA 2018 starts tomorrow, looking forward to it.

Stay tuned.

Friday, April 13, 2018

Enhanced Recovery After Surgery (ERAS): The Way To Go

Dr. Michael Scott

My experience with surgical site infection (SSI) risk reduction is a mixed bag. Perhaps our interventions were seen as too infectious disease oriented and not in line with a global surgical quality approach.

What was desperately needed was a comprehensive, bundled approach to surgical safety with ownership by anesthesiologists and surgeons, where reduced surgical site infections are a secondary yet important collateral benefit.

Enter Enhanced Recovery After Surgery (ERAS) protocol!

I refer you to this excellent review article on ERAS published in JAMA Surgery by my VCU colleague, Dr. Michael Scott. The topic was presented at VCU Department of Medicine Grand Rounds on 4/12/18 by Dr. Scott. 

Enhanced (early) recovery after surgery results in fewer complications and fewer infections.

More information at the ERAS site

I am off to SHEA 2018 next week, stay tuned.

Monday, April 9, 2018

HAI Surveillance: Still Searching for the Sweet Spot with Goodhart's Law in Mind

Professor Charles Goodhart
It seems with much of what we do in infection prevention, we are searching for the sweet spot, whether it is a in how we isolate patients with contact precautions or how we order diagnostic tests (test stewardship).

I read with great interest this article in Clinical Infectious Diseases on partially automated vs. fully automated surveillance systems for hospital acquired infections. No system is perfect and both approaches have some value.

My personal bias: we should standardize and automate as much as possible but only for clinically relevant outcomes with agreed upon infection prevention risk reduction processes.  Why aggressively monitor what we are unable to change (with the current state of science)? An ongoing element of manual review seems inevitable for now.

Last, beware of gaming. As referenced in the article, any surveillance system is subject to Goodhart's Law, named after British economist Professor Charles Goodhart (London School of Economics)

‘ Any observed statistical regularity will tend to collapse once pressure is placed on it for control purposes because actors will change their conduct when they know that the data they produce will be used to control them.'

We are still searching for the HAI surveillance sweet spot.

Wednesday, April 4, 2018

Take a Dump, Save a Life! The VCU Stall Street Journal Makes Fecal Microbiome Talk Mainstream

You know that the fecal microbiome has gone mainstream when you see posters such as these on the campus bathrooms.  

Published in the VCU Stall Street Journal, and hanging in VCU bathrooms, all you ever wanted to know about fecal microbiome diversity and the benefits of fecal microbiota transplantation for C. difficile infections. 

Take a dump, save a life.

Infectious diseases goes pop culture (sort of)!