Road Trip: Infectious Diseases Lectures in South Hill, Virginia

It was a fine spring morning and we were up for a road trip to South Hill, Virginia.


The mission:  to deliver a set of  infectious diseases lectures for continuing medical education to our colleagues at Community Memorial Healthcenter.


We were well received by our affable hosts. Too bad I could not stay and explore the setting a bit more. I had to dart back to VCU Medical Center to supervise my internal medicine ward team.


The next road trip: Honduras, June 2012. Stay tuned.

With Dr. Mike Stevens- South Hill, VA

Audible Reminder to Wash Your Hands

Source: HandHygiene.org

Here is an article on the effectiveness of audible hand hygiene alerts upon entering a patient care area. The study was published in the American Journal of Infection Control.

Investigators in the UK utilized an electronic motion sensor–triggered audible hand hygiene reminder  that was installed at hospital ward entrances. The alert played the following message: “Please clean your hands with hand rub dispensers when entering or exiting any clinical ward."

Trained hand hygiene observers were utilized to document hand hygiene pre/post the intervention.

Three thousand hand hygiene opportunities were observed. Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%, respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5% to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P< .001).

It is encouraging to see an improvement in hand hygiene with a simple, electronic and automated intervention. The baseline hand hygiene of 7.6 % in the study ward is alarmingly low and an improvement to only 50% is also concerning. More work needs to be done there.

Nevertheless, electronic hand hygiene monitoring systems, in my opinion, can play an important role in improving compliance.

Hospital Acquired Infections and Hospital Readmissions

Zero infections? Not likely.

Here is a study published in Infection Control and Hospital Epidemiology and a related article in Infection Control Today of the impact of hospital acquired infections on hospital readmission. 


Using multivariable modeling on a retrospective cohort of patients in a tertiary-care, academic hospital over a 7 year time frame, the investigators demonstrated that a positive clinical culture for MRSA,VRE or C.difficile 48 hours after admission (hospital acquired infection) was a associated with a 40% increased risk of hospital readmission.


This adds to the body of literature on the relevance and impact of hospital acquired infections. Additionally, this supports the rallying call for evidence based infection prevention efforts. However, a word of caution is in order. Not all hospital acquired infections are preventable.The goal of zero infections may not (yet) be attainable. If you are skeptical, read on here, from the research committee of the Society of Healthcare Epidemiology of America. In brief, knowledge gaps exists in pathogenesis, epidemiology, and infection prevention strategies. These are not insignificant.


Expectations must be realistic.

Contact Precaution Uncertainties

I am back on the internal medicine ward service for the next 2 weeks, so will likely be blogging 'light' given the volume of patient care.


 I came across an intriguing article last week titled 'Uncertainty in the application of contact precautions', in press in Clinical Infectious Diseases. The study authors distributed a voluntary, paper survey at a meet-the-professors session at the 2011 Infectious Diseases Society of America meeting in Boston.  


There were a total of 34 respondents. A majority of the survey respondents used contact  precautions for the care of patients colonized or infected with multi-drug resistant organisms.  Only 38% of the participants believed that contact precautions , as currently practiced, prevents the transmission of drug resistant pathogens and 26% felt that they prevent the transmission of all pathogens. Last, 74% of respondents were concerned that contact precautions may cause harm. I have blogged about the adverse consequences of contact precautions before.


Of course, these 34 survey respondents are not representative of all infectious diseases specialists and hospital epidemiologists. The findings, however, highlight an important, ongoing concern, specifically that a knowledge gap exists on how to best apply contact  precautions in different settings so as to maximize benefit while minimizing harm.   

Glove Usage and Hand Hygiene Compliance

I am currently researching and writing a review article on contact precautions and the use of gowns and gloves for the control of drug resistant pathogens.


One concept that I have explored is the negative impact of glove use on hand hygiene. Here is a provocative article titled Wearing gloves: the worst enemy of hand hygiene? Another article published in the American Journal of Infection Control, by the same lead author, investigated the impact of improved glove usage on hand hygiene. Quite simply, greater compliance with gloving does not necessarily result in improvements in hand hygiene. There are dirty hands in the gloves.

My opinion? The promotion of glove use must be accompanied by concurrent and ongoing hand hygiene education. In our controlled trial of universal gloving, hand hygiene adherence was sustained during universal gloving by ongoing hand hygiene education and adherence monitoring.


The message is rather simple: wash you hands before and after donning gloves. There are no shortcuts.

Surveillance for Bloodstream Infections- Reliability and Variability

Source: mhcc.maryland.gov

Here is a timely article published in Clinical Infectious Diseases on the reliability of central line associated bloodstream infections (CLABSIs) surveillance.


Overall, 114 patient records were reviewed by 18 infection prevention specialists, the majority of whom specified they followed National Healthcare Safety Network (NHSN) criteria. The overall agreement amongst infection preventionists by kappa was 0.42 (SE 0.06). Better agreement was observed with a simple laboratory-based definition with an average kappa of 0.55 (SE 0.05). The proportion of patient records that 18 reviewers reported with CLABSI ranged from 14% to 39% (overall mean 28% with a CV of 25%). Again when simple laboratory-based methods were applied to patient records, classification was more consistent with CLABSI assigned in a proportion ranging from 36% to 42% (overall mean 39%).


The findings are significant for several reasons. First, despite training, certification and the use of a standardized CLABSI definition, application can be nuanced and is subject to interpretation based on individual cases with complex clinical conditions. At play here is the concept of inter-observer reliability. This is not a new concept. Here is an interesting study highlighting how the assessment of chest x-rays for pneumonia can differ between radiologists.


More importantly, the above CLABSI finding calls into question the methodological limitation of publicly reporting hospital acquired bloodstream infections. Despite a standardized CLABSI definition, the reliability of surveillance to appears not be ideal for the public goal of inter-hospital comparisons. 

Cockroaches as Vectors of Drug-Resistant Hospital Acquired Pathogens

Blatella germanica- a nosocomial nuisance

Researchers from Ethiopia and the USA have reported that cockroaches can carry multi-drug resistant pathogens. The report is published in Antimicrobial Resistance and Infection Control.


A total of 400 Blatella germanica roaches were aseptically collected for five consecutive months.  Pathogens such as Klebsiella oxytoca, Klebsiella pneumoniae, Citrobacter spp. Enterobacter cloacae, Citrobacter diversus, Pseudomonas aeruginosa,  Enterobacter aeruginosa, Salmonella C1, Non Group A streptococcus, Staphylococcus aureus, Escherichia coli, Acinetobacter spp. and Shigella were isolated both from the roaches internal and external organs. Multi-drug resistance was seen in all organisms.


The fact that cockroaches carry pathogenic bacteria has been reported for many years and should not be surprising. Here is another recent publication on the proposed role of cockroaches as vectors of hospital acquired pathogens.


In my opinion, there are greater risk factors for hospital acquired infections, such as poor hand hygiene and the improper insertion and use of invasive devices. However, if you find yourself in a clinical setting with visible cockroaches, be concerned as this is a direct marker of ineffective pest control and a surrogate marker of poor infection prevention efforts.