Thursday, September 22, 2016

The Mask of the Red Death, Cholera and a Good Read on Infectious Diseases

It was just the other day that I learned that the short story, The Mask of the Red Death, written by Edgar Allen Poe, was inspired by the events of a society ball held by German poet Heinrich Heine. The ball was held in the midst of the 1832 Paris cholera epidemic which claimed 19,000 lives in total. During the ball, a harlequin dancer felt a chill in his legs and took off his mask, revealing a violaceous face. The chlolera symptoms had begun. By the end of the night, several party goers, along with the harlequin, were dispatched to the famed Hotel-Dieu where they later died of cholera.

For infectious diseases nerds, such as myself, here is a good read titled Pandemic by Sonia Shah. The author explores the emergence of new pathogens and pandemics, including cholera, in both a scholarly and gripping fashion.

Outbreaks do not occur randomly, rather, they are the consequences of expanding urbanization, deforestation, crowding, poor public health infrastructure, misuse of antibiotics and globalized, highly connected travel.

Good read.

Monday, September 19, 2016

Contact Precautions for the Control of Endemic Pathogens: The Ongoing Debate

I will be debating my esteemed colleague, Dr. Dan Morgan (University of Maryland) on the use of contact precautions for the control of endemic MRSA and VRE at the 2016 ID Week National Meeting (October 2016).

The topic is contentious with many, myself included, on the side of not employing contact precautions for the control of endemic MRSA and VRE. A robust and highly reliable horizontal infection prevention program is generally sufficient to control these pathogens, as has been our experience (summarized here). 

More recently, a paper published by colleagues of mine in California, supports our horizontal approach to controlling endemic pathogens, suggesting that elimination of routine contact precautions for MRSA and VRE can be done safely.

Looking forward to the debate.

Friday, September 16, 2016

Hand Hygiene Automated Monitoring Systems- Not Yet Ready for Prime Time

Back in 2009, Dr. Mike Edmond and I studied (probably) the 1st generation hand hygiene sensor technologies and published it in the Journal of Hospital Infection.  This technology sensed alcohol on healthcare worker hands and significantly increased compliance with hand hygiene (>90%). The study was small, involved a single unit with motivated and consented nursing participants. No clinical outcomes were assessed. Real world, sustained applicability was neither attempted nor demonstrated.

Monitoring hand hygiene is not easy and no infallible strategy exists to do so, as summarized here.         

We are once again attempting to implement, assess, and study hand hygiene monitoring technology in our hospital, this time using a stepped wedge trial design. The challenges are many, as very nicely summarized in this recent publication.   Having initially overcome the cost barriers, we are seeing hurdles such as getting front line worker buy-in, accuracy (when compared to the gold standard of direct observation), acceptability of being monitored, minimizing work-flow disruption and engagement of data and feedback. 

Hand hygiene technologies for monitoring compliance may have a significant role in the near future however it is not yet ready for prime time.          

Monday, September 12, 2016

Stethoscope Decontamination- What Works Best?

Last week I did an interview for Medscape on healthcare worker contamination (hands, clothes, instruments) and its impact on potential cross-transmission of pathogens to patients. Although the proportionate impact of apparel and stethoscopes on infections is unknown, it is generally believed that 20%-40% of all hospital acquired infections are due to cross transmission from the inanimate environment.

It is well known that healthcare worker apparel can carry a significant bioburden, as summarized here in this SHEA Expert Guidance paper. Stethoscopes, too, become colonized with pathogens such as MRSA.

Many (myself included) advocate wiping down stethoscopes between cases.This is typically done with alcohol wipes. This recent article in the American Journal of Infection Control suggests that chlorhexidine (CHG) would be a better option for stethoscope disinfection as the residual effect CHG can inhibit stethoscope re-contamination for up to 4 hours. Simple and easy with a potential benefit of enhanced bioburden reduction.

Perhaps it is time for us to rethink our disinfectant of choice for stethoscopes.

Tuesday, September 6, 2016

Pragmatic Studies and Vancomycin for Recurrent C. difficile Prevention!

I like pragmatic studies, as previously written here.

Here is an article on the efficacy of oral vancomycin for the prevention of recurrent C. difficile. Now this is by no means a slam dunk article in support of oral vancomycin as preventive therapy for patients receiving systemic antibiotics and who have a history of prior C.difficile infection. The authors reported a significant decrease in C. difficile infection in patients receiving prophylaxis (4.2% vs 26.6%).

While this may not be the optimal, prospective, randomized study, a vexing and important clinical problem, the prevention recurrent C. difficile infection, is tackled by assessing existing data via a formal retrospective methodology, a pragmatic solution. Important clinical questions remain such as what is the optimal dose of vancomycin (or another agent, such as fidaxomicin), duration of treatment, and the impact of prophylaxis on the fecal microbiota?

Regardless, this pragmatic study gives us some empiric data to guide our 'real life' management of recurrent C. difficile prevention. 

The use of oral vancomycin to prevent C. difficile recurrence in patients on systemic antibiotics is not just hocus pocus.

Monday, September 5, 2016

Labor Day 2016: Back from Argentina, Back to Work

Back at work after spending the last 10 days in my native Argentina on a family visit.

Those who know me are well aware of my passion for futbol (soccer) so it should be no surprise that I managed to get to a match in, Racing Club (Buenos Aires) vs my hometown team of  Club Atletico Talleres de Cordoba . The day was cold, wet and windy, apt for those who are passionate about football.

Laboring on Labor day, back at it.

Tuesday, August 23, 2016

Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in Healthy Individuals- We May not Want to Know

What do we do with healthy individuals who are fecally colonized with extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae? Recently, it was reported that nearly 15% of healthy patients are ESBL colonized.

Some are already advocating active detection (screening) and isolation of patients who are ESBL colonized.

This is reminiscent of MRSA active detection and isolation argument and of the 'look before you leap' issue, previously articulated by my colleagues Drs. Michael Edmond and Dan Diekema in this article.

Bottom line, there are too many unknown variables regarding ESBL active detection and isolation. What is the real risk of invasive disease in healthy patients with ESBL colonization? What is the risk to others? How long does colonization last? How do we decolonize such patients (and no, fecal transplants for decolonization do not seem feasible)? What sort of cost and labor will screening entail to front line providers and hospital laboratories? What impact will this have on patient throughput?

Last, many of us are reconsidering contact precautions for endemic pathogens, as summarized here. Thus, what incremental benefit, atop a robust horizontal infection control program,  will contact precautions add to the control of ESBL in endemic settings?

Too many questions, too few answers.

We need to be thoughtful and not reactionary with respect to ESBL control in the healthcare setting.