Daily Chlorhexidine Bathing in Critically Ill Children

We are now promoting daily chlorhexidine bathing of all adult patients at VCU Medical Center. The infection prevention benefits of chlorhexidine have been mentioned here.  Due to potential concern about toxicity of chlorhexidine in pediatric populations, the roll out of chlorhexidine bathing excludes children in our institution.  Here is an article in The Lancet on chlorhexidine bathing in pediatric populations that may drive a practice change.

The investigators used an un-masked, cluster-randomized, two-period crossover trial across ten pediatric intensive-care units at five US hospitals. Patients older than 2 months  were randomly assigned a daily bathing routine of  standard bathing practices vs. a cloth impregnated with 2% CHG.

Analyses were intention-to-treat (ITT) and per-protocol (PP).

A total of 4947 pediatric admissions were eligible for analysis. In the ITT population, a non-significant reduction in incidence of bacteraemia was noted with CHG bathing (3·52 per 1000 days, 95% CI 2·64—4·61) compared with standard practices (4·93 per 1000 days, 3·91—6·15; adjusted incidence rate ratio [aIRR] 0·71, 95% CI 0·42—1·20). 

In the PP population, incidence of bacteraemia was lower in patients receiving CHG bathing (3·28 per 1000 days, 2·27—4·58) compared with standard practices (4·93 per 1000 days, 3·91—6·15; aIRR 0·64, 0·42—0·98). No serious study-related adverse events were recorded..

The results may not be a slam dunk, however, these data suggest that daily bathing of pediatric patients with 2% chlorhexidine may reduce the risk of bacteremia (bloodstream infection). Just as important, the practice appeared safe. 

More to come on this issue, without a doubt. 

VCU News- VCU Infection Prevention Program and a Horizontal Infection Prevention Strategy

Dr. Mike Edmond at ID Week 2012

Here  is a quick news item from VCU News highlighting the success of our horizontal infection control strategy. 

The results are noteworthy. High compliance with hand hygiene and focusing on other simple, data driven infection control measures in our medical, surgical and neuroscience intensive care units resulted in reduced rates of methicillin-resistant Staphylococcus aureus (MRSA) infection by 95 percent over 9 years. 

Most importantly, these intervention similarly decreased infections by other pathogens.

Common sense infection prevention strategies work.

The Arrythmogenic Potential of Pneumonia

Here is an intriguing read that I discovered while flipping through the American Journal of Medicine.The study focused on cardiac arrhythmias in patients hospitalized with pneumonia.

The investigators conducted a national cohort study using Department of Veterans Affairs administrative data including patients aged ≥65 years hospitalized with pneumonia . The arrhythmias included atrial fibrillation, ventricular tachycardia/fibrillation, cardiac arrest, and symptomatic bradycardia. 

Of the 32,689 patients examined, 3919 (12%) had a new diagnosis of cardiac arrhythmia within 90 days of admission. Atrial fibrillation was the most common arrhythmia identified. Increased risk of cardiac arrhythmia was associated with increasing age, history of congestive heart failure, and a need for mechanical ventilation or vasopressors. 

These findings suggest that 10% of elderly patients hospitalized with pneumonia had a new onset arrhythmia within 90 days. The study did not determine if the arrhythmias were associated with an increased mortality.

So in the end, the impact of these arrhythmias on patients with pneumonia is unknown. Interventions and therapies to minimize pneumonia associated arrythmias also remain undefined.

Infections and their complications continue to vex us.

What Value Is There in the Yearly Physical Examination?

What value is there in the annual physical examination? This is a controversial area and the data to support the health and mortality benefit of a yearly check up are sparse.

Here is a related article in the New York Times and a systematic review (open access) in BMJ by the Cochrane Library.

To be clear, there is little controversy about the importance of regular exams for well babies, children and pregnant women, and the value of specific exams, like a Pap smear for sexually active women and a colonoscopy for people over 50. The Cochrane review of randomized trials suggests that general health checks in adults may not reduce morbidity or mortality from disease, particularly cardiovascular disease or malignancies. 

Like much of what we do in medicine, the general health check is not supported by by strong clinical data. 

Congratulations Gaby Halder- Investigator of Water Sanitation and Diarrheal Illness in Rural Honduras

Kudos to VCU medical student Gabriela Halder. As a member of our 2011 Honduras medical relief brigade, Gaby completed a research project on water sanitation and self-reported diarrheal illness. 

This project was presented at the American Public Health Association Annual Meeting in 2011, where she was awarded 1st place in the International/Global Health Student Assembly’s poster presentation. Gaby was also recognized by the VCU School of Medicine.

The manuscript, titled “Water sanitation, access, use and self-reported diarrheal disease in rural Honduras” has been accepted for publication in the Journal of Rural and Remote Health. 

The publication is expected in March/April of 2013.

Stay tuned.

Samantha DeAlto- Peace Corps Health Volunteer in Cameroon

Samantha DeAlto

For followers of this blog, you have likely noticed that the content is heavily infectious diseases, public health and medical relief work. As such, it is only natural that today's post focus on medical relief work in Africa, this time by my next door neighbor.

Samantha DeAlto recently returned from Cameroon where she was a Peace Corps volunteer. As  a health volunteer for 27 months, Samantha educated people on hygiene, sanitation, life skills, birth spacing, breastfeeding, women’s empowerment, nutrition and malaria. 

As you will learn in this article published in the Richmond Times Dispatch, Samantha's experience was transformative and deeply meaningful.

Congratulations.

Honduras January 2013, In Pictures

I am back in my comfortable stateside home. 

For those of you interested in our trip, these pictures tell much of the story.

Further details on this trip and our medical relief work can be found on this blog, my website and on the GH2DP website.

Honduras Day 6: January 18, 2013

Always scheming- with Dr. Mike Stevens

We are headed home, about to board our flight back to the USA.

The trip has been a tremendous success.

Check back in late May 2013 for updates on the medical relief trip as it unfolds.

Hasta luego.

Honduras Day 5: January 17, 2013

We are back in San Pedro Sula, at the Hilton after a successful week in Olanchito and La Hicaca. 

Below are some choice pictures.

Back to the USA tomorrow.

Honduras Day 3-4: January 15 and 16, 2013

We started off another early morning in Olanchito with a delicious Honduran breakfast at the Hotel Beverly. 

By 8 am, we met with nurse Sara Hernandez of the Ministry of Health. The topics of discussion were the ongoing water filter project, mass de-worming of intestinal parasites and women’s health maintenance. Then, we reviewed epidemiologic surveillance confirming the positive impact of the water filter project on the incidence of diarrhea in La Hicaca and environs.

Next, we pressed on to La Hicaca for a round of meetings with community leaders. The village was rustic and gritty, per usual. We hiked up to the town’s water cistern, to view firsthand the inadequacy of the general water supply. This year, we will expand the water filter project by approximately 160 filters to provide water purification units to essentially the entire population of La Hicaca and surrounding area (2000 people). Much of this is driven by the success of last year’s water sanitation research study, completed by Jackie Arquiette.

Audrey Le completed an indoor air pollution research study last year. In collaboration with local community leadership, we will embark on an indoor air pollution education project, as requested by local leaders to correct the problems of indoor smoke induced respiratory problems. The goal is to educate and empower the local community to modify their cook stoves and chimneys to limit smoke in the homes. Other goals for the next brigade are to supply additional speculums for pap smear testing, glasses and dental extraction services. 

As we wandered through the village, we made a few medical housecalls.

In the evening, we settled down in the home of a local family. Our gracious hosts fed us a delicious meal of beans, rice, tortillas and cheese. We spent the night in rustic Honduran homes and got a true flavor of life in the country. In the absence of electricity, candles would have to suffice as our reading lights.

By 3 AM the cacophony of roosters, chickens and pigs adjacent to the window was overwhelming. I dialed up the volume on my headphones to drown out the noise but no such luck was in order. In rural Honduras, there is no sleeping in late. The early morning view from the mountainside is always breathtaking, making it all worthwhile.

After a breakfast of tortillas, beans, eggs and black coffee, we set off for the neighboring village of Lomitas to meet with local community leaders. This year, we will hold two days of clinic in Lomitas to better target the more distant surrounding aldeas (villages). Water filters will also be distributed on site in Lomitas this year.

By noon, we had lunch in a hillside, country home with a spectacular view of the surrounding mountains. Honduras is as topographically beautiful as it is financially poor.

The 2013 relief trip is taking form. As always, our overarching goal is to sustain a collaborative, longitudinal project to maximize the health of the local community, as I have previously explored in a blog.