Tapeworm! A Weekend in the Hospital

Well it has been a fine weekend in the hospital, busy yet not mundane.

I strolled down to the microbiology lab to personally view the 6 foot tapeworm passed by one of our patients, an immigrant from North Africa.

A little diagnostic variety and novelty keeps us on our toes.

Fidelity in Hand Hygiene- Need for Greater Rigor

Five Moments of Hand Hygiene. Source: WHO

We often make interventions in hospital epidemiology without having a robust measure of compliance with practice. An example is chlorhexidine patient bathing, a seemingly simple procedure which is difficult to measure both qualitatively and quantitatively.  

The degree to which an intervention is appropriately and thoroughly completed is fidelity.

Take the example of hand hygiene interventions, considered sacrosanct in infection prevention. How are these measures truly implemented? Here is a telling publication that assessed fidelity with respect to hand hygiene studies. In a systematic review of 100 studies, only 8 reported full measures of fidelity to the protocol.

If research protocols are unable to report compliance (fidelity) with implementation of interventions, then adoption to scale by other institutions is very challenging.

This is troublesome.

VCU School of Medicine Student Research Day- May 5, 2016

I briefly attended the VCU School of Medicine Student Research Day. Laura Pedersen presented her poster on hand hygiene in the OR.

Both Laura Pedersen and Matt Nottingham, who studied the use of Tru D- UVC for the disinfection of anesthesia work stations, will present their work at the SHEA 2016 Spring Conference.

Kudos to both, more to come. 

Antibiotic De-escalation in the ICU- Measures of Impact?

Most infectious diseases physicians and intensivists would agree that de-escalation of antibiotics is a good thing. Trimming unnecessary antibiotic use could enhance safety for the patient and potentially decrease the risk of drug resistant pathogens to others in the environment.

Although the above is sensible and biologically plausible, can we prove this?

Sadly, the medical literature suggests that we have a long way to go in our efforts to be convincing antibiotic stewards. Take a peak at this systematic review on antimicrobial de-escalation in the ICU, published in Clinical Infectious Diseases.  First, there is no uniform definition of antibiotic de-escalation. Second, we have yet to  prove that de-escalation impacts bacterial resistance patterns, antimicrobial cost, length of stay and patient outcomes.

These huge knowledge gaps significantly limit the ability of antimicrobial stewardship programs to affect change and measure success. 

Daunting.

2016 VCU Shining Knight Gala

This past weekend I had the honor of attending the 2016 VCU Shining Knight Gala, to benefit injury and violence prevention programs at VCU Medical Center.

The event, hosted at the Richmond Convention Center, was attended by over 400 guests.

For information on the VCU Injury and Violence Prevention Program, a truly noble project, click here.

Antibiotic-Associated Encephalopathy- Beware

In my opinion, antibiotics are overused largely because they are effective and generally safe. However, adverse consequences occur and include more than just rashes, nausea, diarrhea and renal insufficiency. Here is an excellent review on antibiotic-associated encephalopathy published in the American Academy of Neurology.

Delirium is common in hospitalized patients yet antibiotics, although overused, are under recognized as a cause of confusion.    

The authors report 3 unique clinical antibiotic associated encephaloptahy syndromes: encephalopathy commonly accompanied by seizures or myoclonus arising within days after antibiotic administration (cephalosporins and penicillin);encephalopathy characterized by psychosis arising within days of antibiotic administration (quinolones, macrolides, and procaine penicillin); and encephalopathy accompanied by cerebellar signs and MRI abnormalities emerging weeks after initiation of antibiotics (metronidazole). 

Perscriber beware, antibiotics are not harmless and the side effects can include the precipitation of acute confusional states.

Social Spending and Tuberculosis Burden: A Global Perspective

The last week was a bit punishing for me on the infectious diseases consult service. The Gods of Infectious Diseases must have been displeased with me.

Finally back to the blogosphere and finally a paper in a scientific journal that addresses tuberculosis as a social issue and not merely a medical one.

Here is an article published in the Lancet Infectious Diseases on the association between spending on social programs (in % GDP) and the burden of tuberculosis.

Overall, social protection spending levels were inversely associated with tuberculosis prevalence, incidence, and mortality. For a country spending 0% of their GDP on social protection, moving to spending 1% of their GDP was associated with a change of -18·33 per 100 000 people in prevalence, -8·16 per 100 000 people (-16·00 to -0·27; p=0·043) in incidence of TB. Decreased morality was also observed. This lost significance when more than 11% of GDP was spent.

Epidemiology 101: Correlations do not prove cause and effect, but they do generate valuable hypotheses. In this example, it is well known that TB (and other illnesses) are a function of poverty, crowding, sanitation and malnutrition. Social spending alleviates these negative health pressures. There is plausibility in the argument that social spending may impact certain health outcomes.

Poverty has negative health consequences. That much is irrefutable.