Declining interest in ID: Paul Sax interviews Mike Edmond and Wendy Armstrong

Open Forum Infectious Diseases has a podcast feature, which I highly recommend. The latest installment is a very insightful discussion of the future of ID as a specialty, and how we should respond to the decline in fellowship applicants. We’ve covered many of these issues on this blog before, and I encourage you to either listen to (MP3 link) or read (transcript) this interview.

New rule

Devices that contain a fan and a water source in close proximity should not be allowed in the operating room.

You know the Mycobacterium chimaera story if you read this blog. Shockingly, this single species of non-tuberculous mycobacteria is not the only organism that can be aerosolized by heater-cooler devices.

Is the doctors' white coat evidence of physician economic decline?

We've debated ditching the contaminated white coat many times. In these discussions, I've been struck by responses from colleagues who have clung to the white coat as a symbol of professionalism. I just didn't understand it. There are clearly other, safer ways to identify yourself as a physician, if you feel that is something you need to do. Of course, there are other ways to stay warm or have pockets (cool black vest anyone?) And it's not like the white coat ceremony dates back to Hippocrates or Osler. These modern ceremonies started in 1989 or 1993 depending on your definition.

So why did the modern white coat ceremony emerge and spread across the medical school landscape like...an infectious disease?  I think the answer might be the decline in status of physicians in both healthcare and society. Within healthcare, doctors have been replaced by administrators as primary medical decision makers and in society our salaries pale in comparison to corporate leaders and other professions. Could the white coat (and white coat ceremony) be a vestige of the economic decline of physicians - a psychological defense mechanism?

I was pondering that question, when I came across a fascinating discussion by Malcolm Gladwell on a recent Ezra Klein Show Podcast. In the middle of the interview, around minute 30, they began discussing the decline of journalism. They wondered how members of a profession, who are losing their economic place, respond to this status free-fall. Gladwell was specifically interested in the psychological defense mechanisms that the professional groups adopt when in this free-fall. He says that the group becomes "very particular about who they want to let in or let out, they start to fetishize certain moral stances or positions or codes as a way of enforcing the in-group." Gladwell then discusses a parallel example:

"It is this search for, when you lose one kind of status, one kind of point of differentiation, you have to replace it with something else. A very simple illustration of this is: why are pickup trucks so much larger than they were 25 years ago? Have you ever seen a standard Ford pickup truck of 1975 up against a Ford F-150 of today? The contemporary Ford pickup is literally twice the size...it dwarfs the old one. These are the same people buying those pickup trucks, doing the same jobs, but now their pickup truck is twice as big. And the answer is: in response to the falling economic status of white working class jobs, people have chosen to assert their status in another way. I may not make the kind of money or have the kind economic status that I had 25 years ago, so I'm now going to compensate by having a truck that is twice as big."

It seems that the white coat (ceremony) could be a response to a loss of status of physicians in society. Perhaps this compensatory mechanism would be OK if unwashed, contaminated white coats didn't increase the risk of pathogen transmission in hospital settings. Similarly, large pickups would be OK if they weren't associated with poorer gas mileage and global climate change. Given that physicians have not lost as much power (yet) as journalists or the working class, it might be better to develop strategies to increase our role in medical decision making and maintain our economic status, rather than cling to a cold dirty white coat.

image source: jalopnik.com

Antimicrobial resistance visualized

Click here to view an amazing video that dramatically visualizes the development of antimicrobial resistance.

Hat tip: Brian Hoff, PharmD

Disaggregating the Benefits of Ventilator Bundle Components

There is a very nice study by Michael Klompas and colleagues in September's JAMA Internal Medicine. The team sought to disentangle the benefits or harms of the individual components of current ventilator bundles including: head-of-bed elevation, sedative infusion interruptions, spontaneous breathing trials, thromboprophylaxis, stress ulcer prophylaxis, and oral care with chlorhexidine.

Prior studies had found potential harm associated with stress ulcer prophylaxis (pneumonia) and oral chlorhexidine (higher mortality). This same group published a meta-analysis that called into question the benefits of routine oral care with chlorhexidine (CHG) in ventilated patients. For this retrospective cohort, they examined the associations between exposure to individual ventilator bundle components on a day-by-day basis and ventilator-associated events (VAEs), duration of mechanical ventilation, ventilator mortality, hospital length of stay, and hospital mortality.

The cohort included 5539 consecutive patients who were exposed to mechanical ventilation for at least 3 days. They measured the association between individual process measures and VAEs using Cox proportional hazards regression models with fixed and time-varying covariates and censored patients on extubation or death, whichever came first. Interestingly, they calculated hazard ratios for each bundle component "as the contrast between 4 days of continually performing the process measure vs 4 days of not doing so", since they wanted to allow for the possibility that process measures might have an immediate or delayed effect on each outcome.

I have included the patient-outcomes table below. The most interesting finding, among many tested associations, was that oral care with chlorhexidine was associated with an increased risk for ventilator mortality (HR, 1.63; 95% CI, 1.15-2.31; P = .006). In another table, they reported that stress ulcer prophylaxis was associated with an increased risk for possible ventilator-associated pneumonia (HR, 7.69; 95% CI, 1.44-41.10; P = .02).

This was a very thoughtfully completed and written study - I encourage you to read it (and the accompanying invited editorial) beyond my quick overview. The authors concluded: "we should revisit the classic ventilator bundle. Possible revisions include... a reappraisal of whether oral care protocols should be revised to exclude chlorhexidine therapy, and the reservation of stress ulcer prophylaxis for patients at marked and immediate risk for upper gastrointestinal tract bleeding rather than prescribing them for all patients undergoing ventilation."  It will be interesting to see how slowly these recommended changes occur...

"CAUTI"

There's an excellent commentary on urinary tract infections in the American Journal of Medicine by Tom Finucane, one of my professors from medical school, who is a superb general internist and geriatrician. He argues that UTIs are overdiagnosed and overtreated, and notes that uncomplicated cystitis is usually self-limited, as evidenced by the billions of persons who have recovered from UTIs without antibiotics. And he cites recent studies that challenge the long-held dogma that urine is normally sterile.

What is needed, Dr. Finucane tell us, is a paradigm shift on how we think about UTI. To that end, he suggests "that authors use “UTI” only within quotation marks and that clinicians use the bimanual “air quotes” gesture in discussions. This small, repetitive annotation is intended to disrupt the term’s complacent usage and encourage rethinking of how one manages bacteriuria."

On reading his commentary, I couldn't help but think of posts on the blog over the past few months that question the importance of and even the existence of CAUTI "CAUTI." 

Image: GIPHY.

Goodbye Triclosan (and Triclocarban)

Back when I was an ID fellow, I completed a national survey (along with Anthony Harris) of the availability of tricolsan and triclocarban containing antibacterial soaps. At the time, the industry wouldn't release the use or sales data we needed to estimate a population risk from these chemicals. We found that 76% of liquid soaps and 29% of bar soaps sold to consumers contained these agents. Fifteen years ago we concluded: "with limited documented benefits and experimental laboratory evidence suggesting possible adverse effects on the emergence of antimicrobial resistance, consumer antibacterial use of this magnitude should be questioned."

Well, patience is a virtue. Today, the FDA issued a rule banning triclosan, triclocarban and 17 other agents in hand soaps and body washes. The ban does not apply to antibacterial soaps used in healthcare settings. In a press release, the FDA stated:

"there isn’t enough science to show that over-the-counter (OTC) antibacterial soaps are better at preventing illness than washing with plain soap and water. To date, the benefits of using antibacterial hand soap haven’t been proven. In addition, the wide use of these products over a long time has raised the question of potential negative effects on your health."

It's nice to see positive change happen in your lifetime. It's also nice not to have to read a soap's ingredients before washing our hands.