Wednesday, November 25, 2015

Art Caplan on the white coat

The noted medical ethicist, Arthur Caplan, was interviewed today by Boston Public Radio. He covered a number of topics, including the white coat, and recommended that doctors get rid of both neckties and the white coat on the basis of microbial contamination. He endorsed scrubs as the appropriate attire. Says Art:  "The old white coat is a fine garment, if you're in the 19th century." 

You can listen to the interview here. Scroll forward to hear the white coat discussion at about 8:55.

Friday, November 20, 2015

And another reason to hate contact precautions...

There's a new paper in the Journal of Trauma and Acute Care Surgery that adds to the concern regarding the safety of contact precautions. This retrospective two-year study evaluated approximately 4,400 trauma patients and compared the incidence of venous thromboembolism [VTE] (as detected by active surveillance via duplex ultrasound) in patients who were isolated versus those who were not. I should note that there is an error in the title of the paper as isolated patients also included those on droplet and airborne precautions. However, in most hospitals contact precautions account for the vast majority of patients who are isolated, and even more so in the hospital studied since they performed active microbiologic surveillance for MRSA via PCR. VTE occurred in 17.7% of the isolated patients and 3.5% of the non-isolated patients. After controlling for a number of confounders, isolation remained an independent predictor of VTE (odds ratio 2.6, CI95 1.7-4.0).

Increasingly, hospitals are scaling back contact precautions for MRSA and VRE, and with good reason!

Thursday, November 19, 2015

The white coat debate hits the mainstream media

Today's Boston Globe has an article on the white coat debate. This comes thanks to Dr. Phil Lederer, an infectious diseases fellow at Massachusetts General Hospital, who is working to rid the medical community of the unnecessary, germ-laden garment. You can also hear a great interview with Phil on this topic here.

I'm happy to report that the Infection Control Committee at the University of Iowa Hospitals and Clinics has recently recommended a bare-below-the-elbows approach to inpatient care beginning January 1, 2016.

This will continue to spread--one doctor and one hospital at a time. Incrementally, we will get there.

Graphic: Boston Globe

Tuesday, November 17, 2015

Antimicrobial Stewardship and C. difficile Therapy: It's Complicated

The CDC's Get Smart About Antibiotics Week (November 16-22, 2015) is upon us. To do our part, we bloggers are using this (and hopefully other) posts to "Highlight Get Smart Week on your website" as CDC suggested as an Activity Idea. Of course, the problem with getting smart about antibiotics is that it's really complicated. Sure, reducing unnecessary antibiotic use (e.g. don't treat viruses) seems simple, but the toolkits necessary to assist primary care physicians aren't yet fully developed (e.g. improved rapid diagnostics). And don't even think about inpatient stewardship. I've yet to see antibiotic selection guided by the existence of bacterial multidrug efflux pumps, for example, but hopefully that's coming too. This is not meant to be discouraging, it's just to say that we have a long road ahead and we must keep pushing forward with stewardship-focused basic science studies and clinical trials including implementation science.

With all that in mind, I came across what appears to be an important paper in the November 15 issue of JID by Brittany Lewis and colleagues at Memorial Sloan-Kettering. The authors asked a fairly simple question - what happens to gut flora when it's treated with C. difficile specific therapies and how does antibiotic selection alter colonization resistance to C. difficile, VRE, CRE and E. coli challenges. The authors designed their study around a typical antimicrobial stewardship question: should we treat C. difficile infection (CDI) with metronidazole, vancomycin or both?

Using a mouse model (9 mice per treatment-time point), each was treated for 3 days with metronidazole, vancomycin or both. Fecal samples were then tested for bacterial population diversity (16s sequencing) and susceptibility to C. difficile spore inoculation at 1, 3, 7, 14 and 21 days. As you can see in the figure below, most metronidazole-treated mice could not support C. difficile growth (red circles) after seven days, while many who received vanco or vanco+metro remained susceptible to infection out to 3 weeks. At 7 days and 14 days, 11% and 0% of metronidazole-treated mice were susceptible, respectively. In those treated with vanco, 89% were susceptible at day 3 and 100% were susceptible at day 7. This suggests that vancomycin might increase risk for recurrent infection compared to metronidazole.

Given those findings, it is not surprising that mice treated with metronidazole alone maintained a relatively stable microbiota (See figure below - click to enlarge), which could explain their reduced susceptibility to C. difficile. Among those treated with vanco or vanco+metro, mice with higher levels of disrupted microbial communities were less able to suppress C. difficile growth.

Perhaps more importantly in our fight against antibacterial resistance, a second aim of their study (see figure below) found that mice treated with vancomycin (pink circles) were far more susceptible to VRE, carbapenem-resistant K. pneumoniae and E. coli than metronidazole treated (black circles) or untreated mice (open circles) for at least two weeks post therapy.

In summary, in this sophisticated mouse model, exposure to oral vancomycin was associated with higher risk of C. difficile, a prolonged highly disrupted microbiota and an elevated risk of VRE, CRKP and E. coli colonization compared to those treated with metronidazole alone. There seems to be an increased push to treat CDI patients with oral vancomycin, but given these findings, one wonders if increased utilization of PO vancomycin might be right for an individual patient (although there might be higher recurrence), but wrong for society with increased emergence of VRE, CRKP and other pathogens. After reviewing this study, I'm surely a bit smarter about antibiotics, but unsure of how to treat patients with CDI...and so it goes.

Tuesday, November 10, 2015

Start planning now for SHEA Spring Meeting 2016!

What follows is a guest post from the co-chairs of the SHEA Spring Meeting 2016 planning committee, Silvia Munoz-Price and Tom Talbot (I added the video at the end despite their protestations):

We want to encourage everyone interested in healthcare epidemiology and antibiotic stewardship to plan on attending the SHEA Spring Meeting 2016 in Atlanta. Titled “Science Guiding Prevention,” the planning committee has built on last year’s successful meeting to add more cutting edge, provocative, and diverse topics and speakers to advance key issues surrounding the field. 

In addition to being an outstanding networking platform, this year we will also have: 
  1. A new Antibiotic Stewardship track chaired by Drs. Sara Cosgrove and Kavita Trivedi designed to provide intensive training for directors of stewardship programs. 
  2. Featured plenaries focused on partnership in preventing HAIs with leaders from a wide range of perspectives, including the media, quality improvement scientists, and patient safety advocates. 
  3. The return of the Post-Acute Care/Long Term Care training course, which is now co-organized by SHEA, CDC, and AMDA and chaired by Dr. Nimalie Stone (CDC) and Dr. Robin Jump (representing AMDA). A certificate of participation will be given at the completion of the track (perfect for framing!!!). 
  4. The tried and true SHEA-CDC Training Course in Healthcare Epidemiology, a jam-packed primer on important issues in healthcare epidemiology. Chaired by Dr. Sarah Haessler, this certificate course is perfect for persons new to the field as well as those needing a booster of healthcare epidemiology training. 
  5. The SHEA Foundation Dinner (separate ticketed event) returns with featured speakers Dr. Julie Gerberding and Dr. David Henderson.
  6. Abstract presentations for targeted topics specific to healthcare epidemiology – mark your calendars for the January 29, 2016 submission deadline! 
  7. The launching of the SHEA Mentorship Program.
  8. Finally, we’ve brought back the well-received "Women in Epi" networking event – this year, it will be an evening activity...with drinks instead of bagels!!! 
We’re very excited about the program and hope to see you in Atlanta next spring!

Saturday, November 7, 2015

Lessons from a 1944 CIA manual

The now declassified CIA Simple Sabotage Field Manual was created in the 1940s to help CIA agents “harass and demoralize the enemy”. It came to my attention via Atlas Obscura, and I thought some of the tactics might be familiar to those who work to implement change within hospitals and healthcare systems.

Here is the list of 8 methods for “General Interference with Organizations and Production” (page 28):
  • Insist on doing everything through “channels”. Never permit short-cuts to be taken in order to expedite decisions. 
  • Make speeches. Talk as frequently as possible and at great length. 
  • When possible, refer all matters to committees, for “further study and consideration”. Attempt to make the committees as large of possible—never less than five. 
  • Bring up irrelevant issues as frequently as possible. 
  • Haggle over precise wordings of communications, minutes, resolutions. 
  • Refer back to matters decided upon at the last meeting and attempt to re-open the question of the advisability of that decision. 
  • Advocate “caution”. Be “reasonable” and urge your fellow-conferees to be “reasonable” and avoid haste which might result in embarrassments or difficulties later on. 
  • Be worried about the propriety of any decision—raise the question of whether such action as is contemplated lies within the jurisdiction of the group or whether it might conflict with the policy of some higher echelon. 
Other key advice to managers and supervisors includes: 
  • Hold conferences when there is more critical work to be done. 
  • Multiply paperwork in plausible ways. Start duplicate files. 
  • Apply all regulations to the last letter.
Now go forth and do the opposite!

Saturday, October 31, 2015


I've blogged before about the waste of time, effort and resources being utilized to prevent CAUTI (see here and here), and a new paper in Infection Control and Hospital Epidemiology adds fuel to my fire. This two-year study was performed in the adult ICUs at the Mayo Clinic and analyzed 105 CAUTI episodes. In 97% of cases fever was the primary indication for obtaining the urine culture, but on analysis 2/3 of the patients with CAUTI had alternative diagnoses to explain the fever. Thus it appears that CAUTI is highly over diagnosed. Moreover, preventability is relatively low and secondary bacteremias are uncommon. The authors "question the utility of surveillance for this low-frequency, low-morbidity HAI, which does not serve as a valuable patient-centered outcome." And they conclude: "CAUTIs, as currently defined by NHSN (even with the 2015 definition changes), are not clinically relevant, and efforts to reduce CAUTI may be better directed at other more serious healthcare infections."
The paper is accompanied by an excellent editorial by Dan Livorsi and Eli Perencevich. They thoughtfully dissect all the problems with the CAUTI metric and offer some alternatives. They note that it is debatable whether a NHSN-defined CAUTI represents an episode of preventable harm. And they remind us that the opportunity cost is significant.

It's time to end the war on CAUTI.

Graphic: Living with a Catheter