Paradigm Pause: Contact Precautions for MRSA and VRE Causes Less Harm

There is mounting evidence that discontinuing contact precautions for endemic MRSA and VRE infections atop a robust horizontal infection prevention platform does not jeopardize infection rates and may cause less harm.

Elise Martin et al report a significant decrease in non-infectious adverse events after discontinuing contact precautions for MRSA and VRE at UCLA Medical Center.

Using an interrupted time series analysis methodology,  we recently reported no negative impact of discontinuing contact precautions for MRSA and VRE on already decreasing trends of all device associated infections (including MRSA and VRE).

Since we do not perform active surveillance screening, critics claim that we may be negatively impacting the colonization burden. Also, as we do not perform post discharge surveillance of our patients (is that practical?), critics claim that patients colonized at our institution could manifest infection elsewhere. This is possible yet not probable. As VCU Health is the major safety net hospital of central Virginia, it seems unlikely that our patients would seek care at a private, suburban hospital.

The evidence is mounting for a paradigm change, or at least, for a paradigm pause: for us to thoroughly question the efficacy of contact precautions to control endemic MRSA and VRE.

Storytelling in Medicine: In the Middle of the Night

Today we had a very special Medicine Grand Rounds at VCU Medical Center-where we explored storytelling and narrative in medicine.  

The four invited storytellers included Dr. Megan Lemay, Dr. Pablo Bedoya, Dr. Sam Powell and Dr. Richard Wenzel.

Each shared their experience through patient centered narratives, highlighting important humanistic insights and personal growth. Masterfully done. 

Similar topics explored through medical narratives, reflective writing and art can be found in our Medical Literary Messenger magazine, edited by Dr. Lemay and me.  All content is open access and fully downloadable.

Sunday in the Park with Infectious Diseases: Not All Doom and Gloom!

George Seurat: A Sunday Afternoon on the Island of La Grande Jatte

There have been a lot of visits to my last post-Infectious Diseases in Troubled Waters. Fortunately, not all is not doom and gloom!

This clever article , with a reference to Sunday in the Park With George (the musical based on George Seurat's artistic life), published in Journal of Infectious Diseases, highlights multiple infectious diseases career possibilities.

True. Like a blank art canvas with endless possibilities, a career path can be composed in many fashions.

There is a significant and ongoing need for infectious diseases physicians to manage the emergence of multidrug resistant organisms, antimicrobial stewardship programs, and respond to the growing demands of hospital infection prevention programs. Other career options include public health and private practice.

Not so bad, pay equity notwithstanding. 

Infectious Diseases in Troubled Waters

ID Consults in the hospital: long hours, (relatively) low pay

I have been giving this a lot of thought recently, particularly as I battle with my institution's compensation plan to preserve salaries (note: not increase salaries) and set realistic revenue generation (RVU) expectations. 

Infectious diseases is in troubled waters. In many respects, infectious disease clinical practice is a market failure.

It should surprise few people that infectious diseases specialist are some of the lowest paid physicians, as highlighted here.  Our current healthcare system heavily rewards volume of care and procedures.  Many infectious diseases consults are high complexity, low volume.  We do not perform billable procedures.  None of this bodes well for us.

This NEJM Blog on Why Experienced HIV/ID Doctors Leave Clinical Practice- the push for high volume work and the growing demands of the electronic medical record do not help.

Couple the above with competing expectations to supervise learners and publish academic work, morale plummets.

Academic infectious diseases is in jeopardy, as explored here by Drs. Wenzel and Edmond.

Until there is a fundamental change in the US healthcare system such that the primacy of volume and procedures no longer drives reimbursement, and until universities comprehend the limitations of compensation plans for certain specialties, I see no immediate relief in sight.

Jersey! Where Community Acquired C. difficile is Extremely Rare

Jersey! 

Where the community acquired C. difficile is extremely rare. I am referring to the Channel; Island of Jersey, with only one microbiology lab and a population of <100,000 people, where the majority of C. difficile cases had recent healthcare contact as referenced in this article in Infection Control and Hospital Epidemiology.

This is in contrast to the much cited NEJM article on diverse C. difficile reservoirs. 

In my opinion, the biggest driver of C. difficile is antibiotic (over)use. Antibiotic presciption can have a population based impact on C. difficile rates, as reported here in The Lancet.

Broad formulary restrictions are likely more effective in countries with a National Health Service.  In the USA, absent a well coordinated health system and given the primacy of physician 'autonomy', such an approach would be seen as counter cultural and unacceptable, even if benefits outweigh harms.

Shame on us.

Congratulations Matt Nottingham and Laura Pedersen! VCU School of Medicine Graduates 2018

Drs. Matt Nottingham and Laura Pedersen

A special congratulations to newly graduated medical students- Dr. Matt Nottingham and Dr. Laura Pedersen.

Both published manuscripts with me and presented posters at the SHEA Spring conference. 

Matt's manuscript on UVC light disinfection is referenced here. Laura's manuscript on hand hygiene in the OR and procedure areas is referenced here.

Dr. Nottingham will train in emergency medicine and Dr. Pedersen will train in internal medicine with us at VCU.

Both have very bright futures in the medical profession.

Urine Culture Over Testing and Length of Stay: How to Resonate with Hospital Leadership

Unnecessary urine culture testing is a major issue.  Urine test stewardship is en vogue, as I have previously blogged. 

This paper, recently published in Clinical Infectious Diseases, reports the impact of unnecessary urine cultures on something that is highly relevant to the hospital C suite: length of stay.

Unnecessary urine culture testing results in increased length of stay, likely secondary to excessive treatment.  Increase length of stay negatively impacts patient throughput.  In a volume driven healthcare system, this is what most resonates with administration.

While attempting  to change the culture of urine over testing, make sure to emphasize the impact on length of stay and patient throughput if you seek executive sponsorship and prioritization.

Resist Dogma and Question Paradigms! Bacteriostatic vs Bactericidal Antibiotics

I love it when new data emerges that questions dogma and challenges paradigms.

In the book Pandemic, by Sonia Shah, the author explores the danger of paradigms in infectious diseases.Paradigms are theoretical constructs that provide explanatory frameworks for scientific observations. However, paradigms create expectations, which can limit perceptions and result in confirmation bias and change blindness.

This paper, published in Clinical Infectious Diseases, challenges the dogma that bactericidal antibiotics are a better choice than bacteriostatic antibiotics.  The underlying
paradigm is that a 'cidal' antibiotic more effectively kills bacteria and is thus clinically more efficacious.

Not necessarily true.

As masterfully summarized by the authors, a comprehensive review of the literature does not support this conclusion.  Serum and tissue concentrations, along with pharmacodynamics, are likely more important than the bacteriostatic versus bactericidal qualities of the antibiotic.

Resist dogma and question paradigms.

Reducing Surgical Site Infections: From Global to Local.

Two recent article published in Lancet Infectious Diseases are worth noting.

This paper published by the GlobalSurg Collaborative highlights the disparities in surgical site infection (SSI) rates for gastrointestinal surgery across high, middle and low income countries. Low income counties have a disproportionate burden of SSIs, many (36%) with bacteria resistant to perioperative antibiotics.

What can be done?

This manuscript , published in the same edition of Lancet Infectious Diseases, reports the success of a surgical infection prevention bundle in 4 hospitals across 3 African nations. The bundle included perioperative bathing, avoiding hair removal, surgical hand preparation, patient skin preparation, optimal antibiotic prophylaxis and improved operating room discipline (number of people in OR, room entries etc). Compliance with these measures are reported in table 2 of the manuscript.  The bundled intervention resulted in a 60 % SSI reduction across all sites.

At VCU Health, we employ an SSI risk reduction program under the umbrella of Enhanced Recovery After Surgery (ERAS), lead by Dr. Michael Scott, as previously posted on this blog. Following ERAS implementation, our SSI rate in colorectal surgery has significantly decreased and was presented at SHEA Spring 2018 (Portland, Oregon). 

The manuscript is in process so stay tuned.

A Global Scourge! Carbapenemase Producing Organisms

Source: CBS news

For anyone seeking an excellent review article on carbepenemase producing organisms (CRE) searchno more!

I direct you to this recently published review in Clinical Infectious Diseases. The article highlights advances in laboratory detection strategies and neatly summarizes treatment strategies with combined antimicrobial therapies.

Evidence based best practices for CRE infection prevention are largely lacking. For example, the optimal duration of contact precautions remains unclear, as summarized here in our SHEA Expert Guidance Paper.

A global scourge, indeed.

Thank You Sentara Norfolk General Hospital: Grand Rounds on Infection Prevention

Thank you Sentara Norfolk General hospital for their invitation and generous hospitality. 

Today I delivered Grand Rounds on Infection Prevention: Practices, Processes and Controversies. The lecture was also transmitted via WebEx to 12 Sentara regional hospitals.

Special thank you to Dr. John Brush for his introduction and to Amy Ross, CME Director, for coordinating all aspects of the event.

Lovely spring day in Norfolk, Virginia, with pre-event photos and a post-event, parting view of the bay above.