(Twinrix x 2) x 3 = (0.95) HBsAb+

I recently had a dentist referred to me for treatment of an infection and in reviewing her chart incidentally noted that her hepatitis B surface antibody was negative. In taking her history I learned that after receiving the hepatitis B vaccine series twice (6 doses), she still had a negative hepatitis B surface antibody, which indicates no protection against hepatitis B, a major occupational hazard for dentists.

To the rescue is this important study (full text here). In this study, 48 hepatitis B vaccine nonresponders were given double doses of Twinrix vaccine (combined hepatitis A + hepatitis B vaccine) at 0, 1 and 6 months. At the end of that vaccine series, 95% of the nonresponders developed protective levels of antibody against hepatitis B. This is a very cool finding for healthcare workers who are hepatitis B vaccine nonresponders.

The study isn't new. Dan reviewed it for Journal Watch several years ago (full text here), but I wasn't aware of it and neither were my partners, so I thought it would be important to highlight this paper.

When antibiograms mislead

Whether in our coat pocket or e-device, most of us carry an antibiogram whenever we are seeing patients. The antibiogram is meant to help guide empiric antimicrobial therapy, and usually provides “percent susceptible” for most common bug/drug combinations. However, too many antibiogram users do not understand the limitations of using these aggregate data to treat individual patients. Most understand that hospital-wide antibiograms aren’t applicable across every unit, and formulating unit-specific antibiograms is now common practice.

A more concerning issue, though, is that current antibiogram guidelines recommend including only the first isolate of a given species from each patient, excluding subsequent isolates. While this approach prevents a single patient from having undue influence on the aggregate data, it has the effect of ignoring the risk of emerging resistance during prolonged hospitalizations. In this month’s issue of ICHE, Duke investigators demonstrate the consequences that this approach may have. Read this study for yourself, but the short version: antibiograms lose their predictive utility for Pseudomonas aeruginosa susceptibility by about day 10 of hospitalization for most important anti-pseudomonal agents.

NIH Embraces Hand Hygiene - VIDEO!!!

NIH Director Dr. Francis Collins sings "It's So Easy to Clean Your Hands"... and look out for David Henderson's back-up vocals - talent! All done to celebrate the NIH Clinical Center's first Hand-Hygiene Awareness Day.



h/t Monica Páez

Weekend wrap-up

I'm writing this from my porch on a warm Richmond evening, wrapping up a great holiday weekend with my wife. No clinical work for me this weekend, but did a lot of things--detailed my car, made a big batch of gazpacho, worked in the garden, played the piano, tried to figure out what to do about the yellow jacket nest in the yard, and went to the gym. You know, things that normal people do. It was a refreshing break from the hassles of arguing with insurance companies about why treating MAC pulmonary infection requires more than 5 days of clarithromycin, documenting,  documenting, and more documenting every fricking thing we do, and playing the regulatory compliance game (a game where no one tells you the rules but consultants remind you that what you did do was wrong).

To make the weekend even better, I received the following email from a patient with a 5-month history of relapsing C. difficile infection that I did a fecal transplant on several weeks ago (she graciously allowed me to share it):

Wanted to let you know that it has been a couple of weeks since the transplant and I am back to my old self. My energy is back and so far I'm feeling terrific. Thank you so much for everything you and your staff did to help me. Everyone was so friendly and competent. I want to especially thank your nurse who did a great job in getting me to relax during the (nasogastric) intubation, which was the most uncomfortable part. It feels wonderful not to have to take any more antibiotics. I wish for you and your staff the very best and I hope that this procedure continues to help more and more people who have been going through this debilitating disease. Words cannot express adequately how grateful I am.

Emails like this one serve as a great reminder of why I went to medical school. And it helps to put the bucket of broken into perspective.

As I sit here watching a great blue heron fly over the James River, I can only think that tonight it's all good. Tomorrow, back to the grind!

Graphic:  Anna DeStefano

Postmodern infection prevention

My bad! A few weeks ago I was handing out kudos to APIC for removing all the "getting to zero" propaganda from their website. Was I an idiot or what?! Now zero has become APIC's new vision--Healthcare without infection. All of us would like healthcare without infection. All of us would like automobiles without vehicular accidents, too. But most intelligent human beings who have ever driven a car know that we'll never eliminate automobile accidents no matter how many safety features the auto industry designs. Importantly, we've learned that there are many things we can do to make driving safer. The same holds for healthcare.

I think the zero kool-aid that APIC keeps drinking is really part of post-modernism, the philosophical paradigm that holds there is no absolute truth. Postmodernism is inherently anti-science. David Gorski, a physician who blogs at Science-based Medicine, writes:

"To the post-modernist “scientific medicine is no more valid a construct to describe reality than that of the shaman who invokes incantations and prayers to heal, the homeopath who postulates “healing mechanisms” that blatantly contradict everything we know about multiple areas of science, or reiki practitioners who think they can redirect “life energy” for therapeutic effect. In the postmodernist realm all are equally valid, as there is no solid reason to make distinctions between these competing “narratives” and the “narrative” of scientific or evidence-based medicine."

Stephen Colbert talks about truthiness,"truths that a person claims to know intuitively "from the gut" in that it "feels right" without regard to evidence, logic, intellectual examination, or facts." According to Colbert, “It used to be, everyone was entitled to their own opinion, but not their own facts. But that's not the case anymore. Facts matter not at all. Perception is everything. It's certainty.”

A few years ago, a colleague, also a hospital epidemiologist at an academic medical center, sent me an email that encapsulates the effect of postmoderism on our field. He wrote:

“I used to think that the increased attention on HAIs would be a really good thing, despite the hassles. But I sense that the tide has turned strongly and decisively against the academic, ID-trained hospital epidemiologist. No one defers to that training or expertise anymore–they bow down instead to Toyota models and non-ID trained, self-styled patient safety gurus who preach buzzwords. At my hospital we now report to hospital administration only through someone who spent most of his career in the automotive industry. He's a nice guy and all, but come on, nobody at the table when the “hospital leadership group” discusses infection data has any ID or infection control training!”

If we could be magically transported back a half century with the corpus of evidence about healthcare associated infections that exists today, it might be possible to come close to eliminating HAIs in the hospital of 1962. But advances in medicine continue to make patients more immunosuppressed and devices have become increasingly more invasive. We continue to bypass every one of the body's natural barriers to infection. This is why, as I have said previously, I have yet to meet an infectious diseases physician who believes that HAIs can be eliminated. During my travels I have found that most infection preventionists agree. This leads me to believe that there is some disconnect between APIC leadership and the IPs in the trenches. And it's a good thing I'm not a cynical person! If I were, I might think that APIC's vision would be a great way for the organization to "partner" with industry to prevent infections through some good old fashioned quid pro quo.

I decided when I was a fourth-year medical student that I wanted to be a hospital epidemiologist. I very much wanted to spend my career studying the problem of HAIs and designing ways to reduce them. I still find it fascinating over two decades later. I would love to see the day when there are no HAIs. But I live in the reality-based community that embraces modernism, a place where science is the tool to explain what we observe in the world. So I'll freely admit that I believe in microbiology, epidemiology, vaccines, climate change, and anything else that valid evidence reveals to be true. I also believe that APIC is unfortunately spinning ever further into a parallel, postmodern, anti-science, truthy universe.  

Photos: Institute for Science in Medicine;  BWOG

Outbreak at the rodeo

Infectious diseases continue to plague us and have numerous impacts on society. You probably didn't know that there's currently a horse herpes outbreak in Utah, which is forcing rodeo queens to demonstrate their skills using stick ponies. Click here to read the story and watch the video.

Have a great holiday weekend!

Hat tip:  John Boothby                Photo: KSL

HIV PEP: The sooner, the better

There's a disturbing report in the June issue of Infection Control and Hospital Epidemiology which details transmission of HIV to a healthcare worker following an occupational injury. The provider was placing a central line in a patient with AIDS and cryptococcal meningitis and was stuck with a 25 gauge needle used in the procedure. The patient was HAART-naive and the HCW was HIV negative at the time of the injury. The initial post-exposure prophylaxis (PEP) regimen (combivir + kaletra) provided to the HCW is a CDC-recommended regimen. This was changed to truvada + atazanavir (also CDC recommended) due to diarrhea on the 10th day after exposure. A total of 4 weeks of post-exposure prophylaxis was administered. Sixty days following exposure the HCW developed fever, fatigue and myalgias and was found to be infected with HIV.

Since the introduction of HAART PEP, HIV seroconversion in HCWs has nearly disappeared despite the large number of sharps injuries that occur. Importantly, the transmitted virus had no resistance to any of the antivirals used for prophylaxis. The only potential problem described in the report was that the first dose of PEP was administered 18 hours after the exposure occurred, and one is left to wonder if infection would have occurred if the first dose had been administered sooner. Our goal is to have the first PEP dose on board within one hour of exposure.

Photo: A Medical Resident's Journey