Adjunctive Minocycline for Treatment of Posttraumatic Stress Disorder.

INTRODUCTION: Posttraumatic stress disorder (PTSD) is a chronic, debilitating anxiety disorder. While there is evidence that antibiotics such as minocycline may help to improve symptoms in some psychiatric disorders, no human studies have evaluated their potential as a treatment for PTSD. METHODS: We present results from 4 men aged 33 to 59 years who completed a 12-week pilot, prospective, nonrandomized, open-label clinical trial of adjunctive minocycline for veterans diagnosed with PTSD. RESULTS: All 4 patients showed reduction in PTSD symptoms at the end of the 12-week study, and 3 patients showed reduction in depression symptoms. Observed changes in inflammatory biomarkers are discussed. DISCUSSION: Previous studies have reported increased inflammation in PTSD, though evidence of a potential therapeutic effect of minocycline for PTSD has not been reported previously in humans. CONCLUSION: These findings suggest that antibiotics like minocycline may help to reduce symptoms of PTSD, though further investigation is needed to confirm these findings.

Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial.

Importance: Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor. Objective: To examine whether the frequency of changing reminder signs affects HH adherence among health care workers. Design, Setting, and Participants: This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018. Interventions: Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly. Main Outcomes and Measures: Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group. Results: Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups. Conclusions and Relevance: The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change. Trial Registration: ClinicalTrials.gov Identifier: NCT02223455.

Stenotrophomonas maltophilia Endocarditis of an Implantable Cardioverter Defibrillator Lead.

Stenotrophomonas maltophilia (S. maltophilia) is a nosocomial pathogen and a rare cause of infective endocarditis (IE). Given the intrinsic resistance to many classes of antibiotics, IE due to S. maltophilia carries significant morbidity and mortality among the cases described. Prompt identification of risk factors, particularly the use of medical devices, is necessary for the timely identification of this organism and prompt medical management. We report a case of an implantable cardioverter defibrillator (ICD) lead associated IE due to S. maltophilia and discuss the diagnosis, treatment and outcomes in relation to existing evidence.

Hand Hygiene Among Health Care Workers: Is Educating Patients and Families a Feasible Way to Increase Rates?

BACKGROUND: The Centers for Disease Control and Prevention has recommended teaching patients to remind health care workers to disinfect their hands. However, cognitive impairment among patients may hamper such efforts. METHODS: The St. Louis University Mental Status (SLUMS) Examination was administered to randomly selected inpatients at the Omaha VA Medical Center in Omaha, Nebraska. We asked patients and their families about attitudes toward reminding health care workers to disinfect their hands: willingness, feeling comfortable, and feeling responsible. RESULTS: Of 143 patients, 94 completed SLUMS; 9 had normal mental status and appropriate attitudes. Overall, 16 encounters involved patients or family who were well-suited for giving reminders. CONCLUSION: Programs to encourage hospitalized adults to remind staff to perform hand hygiene may encounter barriers related to cognitive impairment and attitudes.

Other Slow-Growing Nontuberculous Mycobacteria.

The list of clinically important slow-growing nontuberculous mycobacteria (NTM) continues to expand as new species are identified and older ones are found to be pathogenic. Based on pigment production, the strains may be classified as photochromogenic, scotochromogenic, or unpigmented. Some of these organisms are not newly discovered but have heretofore been considered virtually nonpathogenic. Previously, many were regarded as contaminants when isolated from clinical specimens. Ubiquitous in nature, many NTM have been isolated from groundwater or tap water, soil, house dust, domestic and wild animals, and birds. Most infections result from inhalation or direct inoculation from environmental sources. They are not spread from person to person. The infections may be localized or disseminated. In most cases, the optimal regimen or duration of therapy has not been firmly established. The results of in vitro susceptibility testing may be used to select a therapeutic regimen. Many experts recommend clarithromycin with companion drugs such as rifampin and ethambutol for most, but not all, slowly growing species. Aminoglycosides, clofazimine, fluoroquinolones, linezolid, pyrazinamide, or trimethoprim-sulfamethoxazole also may be effective against some strains. Immunocompetent patients with clinically significant infections with NTM usually should receive 18 to 24 months of therapy. Infected immunocompromised patients, particularly those with disseminated infection, probably should receive therapy as long as their immune systems remain impaired. Some of the species discussed include Mycobacterium alsiense, M. celatum, M. gordonae, M. haemophilum, M. kyorinense, M. malmoense, M. simiae complex, M. szulgai, M. terrae complex, M. ulcerans, and M. xenopi.

Education and Communication in an Interprofessional Antimicrobial Stewardship Program.

CONTEXT: Interprofessional education/interprofessional practice (IPE/IPP) is an essential component in medical education and training. A collaborative interprofessional team environment ensures optimal patient-centered care. OBJECTIVE: To describe the implementation of 2 interprofessional antimicrobial stewardship program (ASP) teams using IPE/IPP and to assess the acceptance rate by the primary medical and surgical teams of ASP recommendations for antimicrobial interventions. METHODS: A business plan for the ASP was approved at 2 academic medical centers used for the present study. During a 3-year study period, 2 interprofessional ASP teams included an attending physician specializing in infectious disease (ID), an ID physician fellow, an ASP pharmacist, physician residents, medical students, pharmacy residents, and pharmacy students. Educational seminars were presented for all adult-admitting physicians to discuss the need for the ASP and the prospective audit and feedback process. Cases were presented for discussion during ASP/ID rounds and recommendations were agreed upon by the ASP team. A motivational interviewing face-to-face technique was frequently used to convey the ASP team recommendation to the primary medical or surgical team in a noncoercive and educational manner. The ASP team recommendations for ASP interventions were documented in the medical records. RESULTS: The overall acceptance rate of recommendations by the primary medical and surgical teams were greater than 90% (2051 of 2266). The most frequent interventions provided were streamline therapy (601), route of administration change (452), bug-drug mismatch (190), and discontinuation of therapy (179). Route of administration change was also the most frequently accepted intervention (96%). CONCLUSIONS: The motivational face-to-face communication technique was particularly useful in conveying ASP team member recommendations to the primary medical or surgical teams. Communicating recommendations as a multidisciplinary team in an educational manner seems to have resulted in to greater acceptance of recommendations.

A Profile of Patients Who Fail to Keep Appointments in a Veterans Affairs Primary Care Clinic.

BACKGROUND: Missed medical appointments ("no-shows") affect both staff and other patients who are unable to make timely appointments. No-shows can be prevented through interventions that target those most at risk to miss appointments. Young age, low socioeconomic status, a history of missed appointments, psychosocial problems, and longer wait times are some predictors that previously have been associated with higher no-show rates. OBJECTIVE: To determine predictors for outpatient appointment no-shows in primary care clinics of the Veterans Affairs Nebraska-Western Iowa Health Care System. METHODS: The study included 69,908 noncancelled primary care appointments between January 1, 2012 and December 31, 2013 among patients residing in ZIP codes within the Veterans Affairs Nebraska-Western Iowa Health Care System Service Area. Age, sex, race, presence of a mental health diagnosis, previous no-show rate in the past 2 years, appointment wait time, distance to clinic, and neighborhood deprivation index were extracted or measured for each patient. RESULTS: In log-binomial models accounting for clustering by ZIP code, the strongest predictors of no-shows were age between 20 and 39 (OR compared to 60+: 3.87, 95% CI, 3.48-4.31) or between 40 and 59 (OR compared to 60+: 2.23, 95% CI, 2.05-2.43), black (OR compared to white: 2.14, 95% CI, 1.98-2.31) or other nonwhite race (OR compared to white: 1.35, 95% CI, 1.17- 1.56), male sex (OR compared to female: 1.30, 95% CI, 1.16-1.45), and presence versus absence of mental health diagnosis (OR: 1.16, 95% CI, 1.09-1.24). CONCLUSION: These findings show that individuals who are younger, nonwhite, male, or have been diagnosed with mental health issues are more likely to no-show. Interventions to improve compliance could be targeted at these individuals in order to decrease the burden of no-shows on health care systems.

Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit.

OBJECTIVE: To determine whether hand washing would increase with sustained feedback based on measurements of soap and paper towel consumption. DESIGN: Prospective trial with a nonequivalent control group. SETTING: Open multibed rooms in the Omaha Veterans Affairs Medical Center's Surgical Intensive Care Unit (SICU) and Medical Intensive Care Unit (MICU). SUBJECTS: Unit staff. INTERVENTION: Every weekday from May 26 through December 8, 1998, we recorded daytime soap and paper towel consumption, nurse staffing, and occupied beds in the SICU (intervention unit) and the MICU (control unit) and used these data to calculate estimated hand washing episodes (EHWEs), EHWEs per occupied bed per hour, and patient-to-nurse ratios. In addition, from May 26 through June 26 (baseline period) and from November 2 through December 8 (follow-up period), live observers stationed daily for random 4-hour intervals in the MICU and the SICU counted actual hand washing episodes (CHWEs). The intervention consisted of posting in the SICU, but not in the MICU, a graph showing the weekly EHWEs per occupied bed per hour for the preceding 5 weeks. RESULTS: Directly counted hand washing fell in the SICU from a baseline of 2.68+/-0.72 (mean +/- standard deviation) episodes per occupied bed per hour to 1.92+/-1.35 in the follow-up period. In the MICU, episodes fell from 2.58+/-0.95 (baseline) to 1.74+/-0.69. In the MICU, the withdrawal of live observers was associated with a decrease in estimated episodes from 1.36+/-0.49 at baseline to 1.01+/-0.36, with a return to 1.16+/-0.50 when the observers returned. In the SICU, a similar decrease did not persist throughout a period of feedback. Estimated hand washing correlated negatively with the patient-to-nurse ratio (r = -0.35 for the MICU, r = -0.46 for the SICU). CONCLUSIONS: Sustained feedback on hand washing failed to produce a sustained improvement. Live observers were associated with increased hand washing, even when they did not offer feedback. Hand washing decreased when the patient-to-nurse ratio increased.