Single Occupancy Rooms Required for Contact Precautions and ESBL? Maybe Not

Once again, a paradigm is challenged.

This time, it is the use of single occupancy rooms for  contact precautions and the control of ESBL pathogens. The study was published in The Lancet Infectious Diseases and employed a 16 hospital cluster randomized strategy for contact precautions in single bed room versus contact precautions with multiple-bed rooms for patients with ESBL-producing Enterobacteriaceae cultured from routine clinical samples.Transmission risk assessment was judged by rectal carriage of ESBL-producing Enterobacteriaceae  in at least one wardmate.

Multiple-bed room contact precautions for ESBL-producing Enterobacteriaceae  was not inferior to contact isolation in a single occupancy room.

This provides valuable information for a more pragmatic approach to the use of contact precautions for the control of multidrug resistant organisms, particularly when a scarcity of single occupancy rooms exists. A very Satisfice approach to infection prevention.

Quality and Safety in Healthcare: What Defines a Struggling Organization? Time for Reflection

Source: PeaceLabs.org

It is typically more common for publications to identify what is required for select positive outcomes.  

I like this alternative approach, a publication which defines the characteristics of organizations that struggle with quality and safety.   The paper is PubMed indexed here.

Although the results may not be Earth shattering the findings are important.  The five domains consistently reported by struggling organizations include:

1.  Poor organizational culture
2.  Inadequate infrastructure
3.  Lack of a cohesive mission and vision
4.  System shocks- such as high level personnel turnover, particularly in leadership
5.  Dysfunctional external relations

Although no prescriptive plan is offered, these domains provide a comparative reference and a reflective focus point for organizations struggling to meet safety and quality goals.

All change starts with self (organizational) reflection.

2019 Delaware Communicable Diseases Summit

Thank you to the 2019 Delaware Communicable Diseases Summit organizers for a hugely successful event.  The meeting was held at the Christiana Care Health System.The turnout was spectacular, standing room only.

My colleagues, including Drs. Karyl Rattay, Gary Marshall, Karen Ravin, Deborah Kahal and Karen Lopez, expertly covered a lot of ground on vaccine hesitancy, emerging ID threats, infectious diseases and the opioid epidemic and One Health.

It was an honor to give the lecture on the prevention of healthcare associated infections and to participate in the panel discussion.

As always, I learn more than I contribute.

Sympathy for the Drummer: Why Charlie Watts Matters

I am off topic yet again, no medical writing today, rather music, or drumming to be more specific.

Sympathy for the Drummer: Why Charlie Watts Matters, by Mike Edison, is a book that resonates with those who are rhythmically inclined. Charlie Watts, the legendary Rolling Stones drummer, is a jazz virtuoso turned great rock drummer for The Greatest Rock Band in the World. Once I started reading this book I could scarcely put it down.

Charlie putts the 'roll' in rock and roll, with a minimalist drum set, amazing beats, fills and grooves that both push and pull the rhythm of a song. No need to be flashy, just consistently unique. The Stones need Charlie Watts more than Charlie Watts needs the Stones.

If you think it is easy, try playing along to a Rolling Stones song, beat by beat.

I am in Wilmington, Delaware for the 2019 Communicable Diseases Health Summit tomorrow (12/9/2019). Very much looking forward to it.

Stay tuned.

Re- visiting the panculture and other thoughts

I really enjoyed this clever article titled Re- Visiting the Panculture, available here. The authors, Valerie Vaughn and Vineet Choprak, highlight the waste associated with reflexive panculturing of febrile patients. The call for a more 'mindful' approach to the evaluation of fever  is spot on.

The above concept is applicable to this more recent publication titled Knowledge and practices of physicians and nurses related to urine cultures in catheterized patients: An assessment of adherence to IDSA Guidelines.

So, can we be more mindful when assessing a febrile patient?  

Yes, but education and feedback to  providers only goes so far in my experience. This must be coupled with electronic medical record decision support mechanisms which prompt physicians to practice more guideline concordant care. Sometimes, forcing functions are needed, such as an electronic medical record hard stop on Clostridium difficile test ordering for patients with diarrhea and on laxatives.

Erosion of  provider autonomy is not inconsequential, and should employed selectively at most,  such as when patient safety and resource stewardship is on the line.

Ethical Implications of Recruiting Universal Stool Donors for Fecal Transplants

Source: Yale Global Health Review

Although I have performed multiple fecal transplants for recurrent Clostridium difficile

infections, with donor stool coming from OpenBiome, I have not given much thought to the ethical implications of recruiting universal stool donors. My focus has been on the risk/benefit of the procedure to the patient.

Kudos to my colleague Dr. Susy Hota and her collaborators on this truly unique prospective on the ethical implications of recruiting universal stool donors, published in Lancet Infectious Diseases.

For example, informed consent for stool donors should take into consideration that the microbiome may convey sensitive personal information such as travel history, past exposures and sexual practices and may act as a pressure on various aspect of a donor's lifestyle. The intestinal microbiota is also a source of health information that may guide clinical decision-making in the future. Mechanisms to deal with these issues should be developed. Further consideration should be given on what is appropriate compensation for stool donors.

The role of universal stool donor is not as simple as it appears.

UVC Light Disinfection: Our Experience in BMT and Oncology

Let me be clear, UVC terminal  disinfection of hospital rooms is no panacea, especially when it comes to the prevention of Clostridium difficile infections.

Our biggest impact on reducing Clostridium difficile at VCU Health comes from minimizing over testing through electronic medical record decision support. This includes hard stops on  Clostridium difficile test orders for patients receiving laxatives.

Our experience with UVC light terminal room disinfection, particularly in bone marrow transplant and oncology populations was recently published, PubMed indexed here. Using an interrupted time series analysis, we observed a significant decrease in Clostridium difficile infection rates following the deployment of UVC light disinfection in these specific wards.

The next frontier in Clostridium difficile reduction is class restriction of antibiotics.  This is only feasible with expansion of antimicrobial stewardship programs to 7 days a week coverage.

Stay tuned.