Environmental Cleaning, Revisited with New Technologies

Lately I have been thinking a lot about terminal room disinfection as one of the aspects of our infection prevention program. 

For those of you who labor over similar concerns, here is an informative review on new technologies for room disinfection, published in Current Treatment Options in Infectious Diseases. 

There is no single best method for cleaning patient rooms. Traditional manual cleaning is still the norm however this is labor intensive and subject to issues with compliance and quality. In my opinion, there is simply too much variability in practice and too great a risk for optionalism and human error to make this a truly effective approach.

New technologies, such as UV-light robots and hydrogen peroxide robots allow for "whole room'' disinfection, following a manual wipe down of bioburden and debris. This is promising yet not salvation.These technologies are costly, add additional time to cleaning, decrease patient throughput, require a vacant room (cannot be used while patient remains in the hospital room) and may be damaging to some materials.

Last, we know that the inanimate environment is teeming with pathogens and spores. A precise estimate of the proportionate impact of environmental cleaning on decreasing hospital acquired infections, even with the employment of new technologies, is lacking.

We are still searching for the optimal strategy for cleaning our hospital environment.   

Academic ID in Jeopardy

Here is thoughtful opinion article published in Infection by Richard Wenzel and Mike Edmond.

I thought that many of the comments were spot on. The authors call for  ‘new leadership’ in medicine, one that requires physician CEOs who have not lost sight of humanities and scholarship in medicine, who will protect and preserve the reflective and intellectual aspects of mentorship and academic medicine. 

As stated in the article, the goal is to reward value over volume, to halt the rising trend of churning out patients (volume) at the expense of value (teaching, mentorship and scholarship). The pendulum will likely swing way too far in the wrong direction before this concept gains enough traction for change.

We are still awaiting the right formula for rewarding value.

Can Fecal Microbiota Transplantation Result in Obesity?

Can fecal microbiota transplantation (FMT) result in obesity? Here is an intriguing report published in Scientific American detailing excessive unintentional weight gain in a normal weight individual following FMT. The donor, a relative, also experienced similar weight gain. Of note, there are animal models suggesting that FMT can trigger or contribute to obesity.

We know that FMT is very successful for the management of recurrent C.difficile infection. There is much left to learn in the FMT field such as long term side effects or potential infectious complications from unknown pathogens. 

One case report does not prove a cause and effect relationship between FMT and the onset of obesity. Regardless the finding underscores the need for a national registry or database for assessing both the efficacy and long term impacts of fecal transplantation.

In the meantime, for select patients, specifically, those with recurrent or persistent C.difficile, FMT is a reasonable and valuable treatment option in which the benefits seem to far outweigh the risks.

Forbes: Deadly Germs May Lurk In Your Doctor's Clothing

I was surprised to read an article in Forbes about bacteria potentially lurking on the apparel of healthcare personnel.

Below is a brief an informative video about a typical doctor patient encounter

The inanimate environment is teeming with pathogens. The extent to which this drives bacterial cross transmission is not fully known but it is almost certainly not negligible.

Rethinking the Efforts of the Hospital Infection Prevention Program

Here is a recent message from APIC that caught my eye. It is a call to action of sorts.

We are in pressing times in infection prevention. More than ever, we are expected to implement and drive infection prevention efforts at our hospitals. The public expects preparedness for emerging and re-emerging diseases such as MERS and Ebola. For many infection prevention programs, the demands increase without a commensurate increase in resources and personnel.

As previously mentioned in a prior posting, accessible here, we need better methods for adequately calculating the staff and resource needs of a modern, hospital based infection prevention program.

Bacteremic Sepsis in Transplant vs Non-Transplant Patients- Paradigm Challenge

The conventional thought is that sepsis and bacteremia is more severe and life threatening in transplant recipient patients. The immunocompromised state of the transplant recipient theoretically heightens the severity of illness and increases the risk of a poor outcome.

This recent paper in Clinical Infectious Diseases suggests otherwise. The investigators reported a 78% relative decrease in 28 day mortality between bacteremic sepsis in transplant recipients versus non-transplant recipients.

Although transplant recipients may be immunosuppressed and at risk for opportunistic infections, particularly from viruses and fungi, in the event of bacteremic sepsis they fare better than non-transplanted hosts.Why? It is quite likely that the immunocompromised state down regulates the inflammatory response of sepsis, improving survival.

Once again, empiric data and observation contradict intuition.

Antibiotics Therapy Optimization- Room for Improvement

It is a common opinion that antibiotics are misused in US hospitals. The fears of evolving antibiotic resistance continue to grow.

When empiric antibiotics are prescribed on hospitalized patients, how appropriately are they prescribed and how quickly are they streamlined or discontinued? Here is an article published in Lancet Infectious Diseases which raises concerns in my opinion.

Across 6 US hospitals ( 2 university hospitals, a public community hospital and 3 private community hospitals) over a course of one year, of the 1200 selected patients on antibiotics, 30% had no fever and normal WBC counts, appropriate cultures were obtained on 59% of patients and, after 5 days of therapy, 66 % of patients had no change in their antibiotic therapy. 

Antibiotics are overused, particularly ones with a broad therapeutic spectrum, frequently on patients with no clinical signs of infection or fever. Concerning.

We only have ourselves to blame for the ongoing rise in drug resistance and C.difficile infections.