Urine Sample Collection from Urinary Catheters- Less Than Stellar Practice

In my opinion, it is bad enough that Foley (urinary)  catheters are overused and that urinalysis and urine cultures are ordered indiscriminately with little understanding of how to  interpret the results. To further complicate matters, urine samples on catheterized patients are frequently collected in a suboptimal fashion, as suggested by this article recently published in the American Journal of Infection Control.

In this  study, 76% of nurses surveyed reported receiving education on catheter associated UTI  (CAUTI) risk reduction within the last 12 months. Strikingly, 327 (83%) of all nurses surveyed reported that they never collect urine samples by draining directly from the drainage bag, yet only 58% viewed others to be fully compliant with that standard.

Improperly collected urine sample  will lead to incorrect diagnostic and management decisions.

The overuse of urinary catheters is rampant. Besides ongoing education on urinary catheter use, the effect of which dissipates typically in 6 months, automated mechanisms for daily review and automatic discontinuation orders to limit catheter use are the most consistent and evidence based mechanisms to minimize CAUTIs.

It is to remove the urinary catheters in a consistent and formalized approach.

BIG-LoVE: Respiratory Viruses Uncovered!

The BIG- LoVE  study (Utah- Better Identification of Germs-Longitudinal Viral Epidemiology)- kudos for the catchy acronym, rather clever indeed, especially from a state (Utah) with a prior history of polygamy.

The article can be accessed here and was published in Clinical Infectious Diseases. 

The investigators assessed the viral etiology of respiratory illness by prospectively collecting weekly symptom diaries and nasal swabs for PCR analysis from families for 1 year, analyzed data by reported symptoms, virus, age, and family composition, and  evaluated the duration of virus detection.

Twenty-six households (108 individuals) provided concurrent symptom and nasal swab data for 4166 person-weeks. 

Participants reported symptoms in 23% and a virus was detected in 26% of person-weeks. There were 783 viral detection episodes; 440 (56%) associated with symptoms. Coronaviruses, human metapneumovirus, and influenza A. Viral detections were usually symptomatic; bocavirus and rhinovirus detections were often asymptomatic. The mean duration of PCR detection was ≤2 weeks for all viruses and detections of ≥3 weeks occurred in 16% of episodes. Younger children had longer durations of PCR detection.

So viral detection is common and often asymptomatic. Again, we need to resist using anti-infectives when not warranted. If it is not Influenza- no oseltamavir. Also, if the the clinical presentation is of a viral upper respiratory infection, no antibiotics!

Eventually we will need better diagnostics, one that can detect pathogens and the concomitant inflammatory response, to differentiate between infection versus asymptomatic shedding.

Donning and Doffing Personal Protective Equipment- Dr. Michelle Doll Interview and Podcast

Her are two media highlights on our recent JAMA Internal Medicine commentary, first authored by Dr. Michelle Doll.

The first was published in Reuters, accessible here.

The next, a podcast featuring Dr. Curtis Donskey and VCU's Dr. Michelle Doll, is accessible here.

Click here for the my blog entry on the invited commentary.

Risky Business- Removal of Personal Protective Equipment

Removal of personal protective equipment (PPE) can be risky business as highlighted in this hot off the press article in JAMA Internal Medicine. 

When assessed for the appropriate removal of PPE (gowns and gloves), over  40% of HCWs contaminated themselves through poor technique.

We wrote the accompanying commentary to this article, accessible here. Dr.Michelle Doll elegantly argues in favor of selective use of contact precautions, with improved PPE, calling for enhanced mechanisms of training, evaluation and feedback of healthcare worker donning and doffing of gloves and gowns. To be effective, this must be done to scale, across the hospital environment. 

This is our charge and we moving forward. 

More to come.

It All Comes Down to Implementation!

It all comes down to implementation! 

Those at VCU know that I have been saying this over and over and over, sounding much like a broken record.


Chlorhexidine patient bathing only works if done correctly, as summarized in this paper. The authors utilized a calorimetric assessment tool to assess chlorhexidine concentrations on patient skin following a chlorhexidine bath. The intervention was education of nursing and patients along with monitoring and feedback of bathing performance. Detection of chlorhexidine on patient skin went from a baseline of 46% to 88% following the intervention.

Perhaps there are easier ways to measure completion of chlorhexidine bathing in hospitalized patients. Considerations include product consumption analyses and assessment of bathing documentation in the electronic medical record. These methodologies unfortunately do not measure detectable chlorhexidine concentrations in the skin. Challenging.

It all comes down to implementation.

2015 ID Week- Images from San Diego

I have spent a very busy week in San Diego, at the 2015 ID Week Conference. 

Highlights include meetings and project planning with my colleagues from the SHEA Guidelines committee, presenting a poster and attending some truly superb scientific presentations, including a pro/con debate on bare below the elbows as an infection prevention recommendation. 

The VCU Alumni dinner was also a high point.

Back to Richmond soon.

City View- San Diego

Poster Presentation

Protesters: 'IDSA Lyme Guidelines=Medical Neglect"

Debate question

Debate Response

Sepsis Video: Get Your Sepsy on!

We need not confine ourselves to boring, tedious, online slides sets and modules for our ongoing medical education.

See the video below from Kern Medical Center. Raising sepsis awareness, hammering home critical concepts and management points.

Creative, choreographed, clever.

"Get your Sepsy on"

Soil Transmitted Helminths in Honduras- Internal Medicine Grand Rounds: Dr. Ana Sanchez

Today we had the honor of hosting Ana Sanchez, PhD at VCU's Medical Grand Rounds.

Dr. Ana Sanchez was invited on the Behalf of the VCU GlobalHealth and Health Disparities Program (GH2DP) - Honduras Program. Dr. Sanchez has collaborated with VCU GH2DP on reducing the burden of soil transmitted helminths in rural Honduran populations. The lecture also covered the immunologic and health impact of helminthic infections in resource poor settings.

We were honored to have her visit VCU and to share both her research and our collaborative experience in a Medical Grand Rounds format.

Here is the VCU News article  on the event.

Phenomenal lecture, excellent turnout.

With Drs. Sanchez and Stevens