Medical Literary Messenger Fall 2013: Inaugural Issue Published

It is with great pride that we present you the Fall 2013, inaugural issue of the Medical Literary Messenger.

Download the issue here.

Visit the site at: www.med-lit.vcu.edu

Bacteremia and Mortality from a Urinary Catheter

I am back from Argentina and back to work.

Here is an investigation on bacteremia and mortality associated with urinary catheters.
The author's focused on catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU)  and studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU.

There were 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality.

Bacteremia from a urinary source was an infrequent event. In addition, there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria.  

Catheter associated urinary tract infections are the most common hospital acquired infection yet result in the least morbidity and mortality. This does not negate their relevance, however, in terms of truly impacting patient safety, the most bang for the buck is in the prevention of bloodstream infections and ventilator associated pneumonia. 

Stethoscope Disinfection

Here is a recent publication on stethoscope disinfection.

Stethoscopes are contaminated with pathogenic bacteria and pose a theoretical risk for cross transmission.

Baskets were filled with alcohol prep pads and a sticker reminding providers to regularly disinfect stethoscopes were installed outside of patient rooms. Healthcare providers' stethoscope disinfection behaviors were directly observed before and after the intervention. Multivariable logistic regression models were created to identify independent predictors of stethoscope disinfection. 

Two hundred twenty-six observations were made in the preintervention period and 261 in the postintervention period (83% were of physicians). Stethoscope disinfection compliance increased significantly from a baseline of 34% to 59% post-intervention. In adjusted analyses, the postintervention period was associated with improved disinfection among both physicians (odds ratio [OR], 2.3 [95% confidence interval (CI), 1.4-3.5]) and nurses (OR, 14.3 [95% CI, 4.6-44.6]). Additional factors independently associated with disinfection included subspecialty unit (vs general pediatrics; OR, 0.5 [95% CI, 0.3-0.8]) and contact precautions (OR, 2.3 [95% CI, 1.2-4.1]). 

So providing stethoscope disinfection supplies and visible reminders outside of patient rooms may increase stethoscope disinfection rates. 

The intervention is simple and reasonable and is consistent with a horizontal infection prevention strategy. The actual impact on healthcare associated infections is unknown.

Blogging Light This Week- On Vacation

I am back Cordoba, Argentina for the week and will be bogging light, if at all.

Saludos!

Congratulations Kate Pearson, Jeff Wang and Summer Donovan- VCU GH2DP Researchers at ASTMH 2013

Congratulations Kate Pearson, Jeff Wang and Summer Donovan- VCU GH2DP researchers at the American Society of Tropical Medicine and Hygiene (ASTMH) 2013 Annual Meeting.

As members of our VCU GH2DP Honduras team, they have done valuable research on health services satisfaction and chagas disease knowledge and perception.

L to R: Jeff Wang, Kate Pearson and Summer Donovan

Kate Pearson and Jeff Wang

Kudos!

Risk Factors for Aspiration Pneumonia- A Patient Phenotype

As a clinician I am always looking for clinical pearls. Here is a study that sought to characterize a patient 'phenotype' for aspiration pneumonia.

This was an observational study of 1348 patients hospitalized with community-acquired pneumonia in the United Kingdom. Patients "at risk" for aspiration pneumonia  chronic neurologic disorders, esophageal disorders and dysphagia, impaired conscious level, vomiting, or witnessed aspiration. 

Nearly 14% of the cohort were classified as "at risk of aspiration." These patients were older (median age, 74 years [interquartile range, 60-84] vs 66 years [interquartile range, 49-77]; P < .0001) and more likely to have comorbidities (chronic liver disease 11.3% vs 3.7%, P < .0001; congestive heart failure 28% vs 17.1%, P = .0004; and stroke 26.9% vs 9.5%, P < .0001). Patients at risk of aspiration pneumonia had a poorer short-term outcome (30-day mortality 17.2% vs 7.7%, P < .0001), but after adjusting for their greater severity of illness and comorbidities this difference was not significant (odds ratio 1.05; 95% confidence interval [CI], 0.63-1.76; P = .8). However, patients with aspiration risk factors were at greater risk of poor long-term outcomes with increased 1-year mortality (hazard ratio [HR], 1.73; 95% CI, 1.15-2.58), increased risk of rehospitalization (HR, 1.52; 95% CI, 1.21-1.91), and a strong association with recurrent admissions with pneumonia (HR, 3.13; 95% CI, 2.05-4.78) after multivariable adjustment

Using risk factors to identify patients at risk of aspiration pneumonia may give us a clinical 'phenotype' of patients with greater severity of disease and poorer long-term outcomes.

What value is this? Proving conclusively that an aspiration event caused pneumonia in clinical practice is generally not feasible. The study was also low yield with respect to microbiologic data. These data will likely not alter antibiotic management. However, a better understanding of aspiration risk and prognosis may guide discussions about realistic outcomes and limitation of treatments and may result in meaningful discussion on end of life care.

Hand Hygiene- Revisited

The issue of hand hygiene compliance continues to resurface in our discussions on infection

prevention. Here is an up to date review article on hand hygiene by Dr. John Boyce. 

New electronic methods for monitoring hand hygiene practices are increasingly popular. These interventions are expensive, likely increase compliance with hand hygiene and may be superior to compliance assessments of hand hygiene by direct observation.  As with any method of compliance monitoring, non-punitive feedback to healthcare workers is needed to further encourage improvements in practice.

However, as of today's date, I am unable to find comparative data on the incremental benefit of electronic hand hygiene technologies vs. direct hand hygiene observation with respect to increased hand hygiene compliance and decreased healthcare associated infection rates.

We still have more work to do on the practice of hand hygiene. 

Overt vs Covert Hand Hygiene Observers

Yesterday I spent the morning listening to presentations by vendors of new hand hygiene compliance monitoring technologies. 

In my subsequent meanderings on PubMed I came across this article in PLOS ONE documenting differences in hand hygiene compliance between overt and covert hand hygiene observers.

Of the 23,333 hand hygiene observations 76.0% were by medical students (trained, covert hand hygiene observers), 5.3% by infection control nurses and 18.7% by unit staff. The annual compliance rates were medical students (covert) 44.1%, infection control nurses (overt) 74.4% and unit staff (overt) 94.1%; P<0.001. The medical students found significantly lower annual compliance rates for 4/5 hand hygiene indications compared to infection control nurses and unit staff; P<0.05. 

The results are not surprising. The Hawthorne effect, no doubt.

Organizational Culture and Infection Prevention

Infection Prevention and the Ivory Tower of Implementation

Evidence based infection prevention initiatives may take hold in one institution yet may fail to do so in another. The concept of organizational culture (''the way things are done around here'') may come into play.

Organizational culture, explored in this article, can be equally as difficult to define as it is to change.

There is no one best approach to implementing infection prevention across a healthcare system. The process takes patience and is dependent upon the quality of the data, the organization's mission, education, marketing, champions, facilitators, measurement and feedback.  

We recently explore this theme in a publication titled Pushing Beyond Resistors and Constipators: Implementation Considerations for Infection Prevention Best Practices.

The paper will soon be published in Current Infectious Diseases Reports.

Stay tuned

Contact Precautions Revisited!

The controversy about contact precautions continues. 

I urge you to check out this post and related commentary, a proper intellectual to-and-fro, in the HAI Controversies Blog.

We eliminated contact precautions for the endemic control of VRE and MRSA at VCU Medical center on April 1st, 2013. NO, this was not an April Fool's joke.

As summarized by my VCU colleague Dr. Mike Edmond:

Here's an update: for this past quarter, hospital-wide (~850-beds) we had 1 device related MRSA infection (a CLABSI), and 2 device-related VRE infections (both CLABSI by current definition, though true source likely gut as both were oncology patients). There were no CAUTIs or VAEs associated with MRSA or VRE. No contact precautions for MRSA or VRE for the last 6 months. Housewide device days for the quarter were: urinary cath 11,807, central line 19,610, ventilator 3,431, total device days 34,848. 

Here is our perspective on contact precautions, as summarized in Current Infectious Diseases Reports.

Have a fine weekend.