Impact of mandatory inpatient infectious disease consultation on outpatient parenteral antibiotic therapy

BACKGROUND: Outpatient parenteral antibiotic therapy (OPAT) has had an important impact on infections historically requiring prolonged intravenous antibiotic treatment. Within the past decade, new antibiotics with oral/intravenous bioequivalence, plus recent data on infection management, have increased the potential role of the Infectious Disease (ID) consultant for OPAT. METHODS: We studied the impact of mandatory ID consultation on the use and outcomes of OPAT in patients initially hospitalized. The study was approved by the Institutional Review Board and the Executive Committee of the Medical Staff of Baystate Medical Center. Patients older than 18 years of age being considered for discharge to home on OPAT were identified, primarily through discharge planning. Formal ID consultation was performed to determine both need for OPAT and a variety of issues regarding antibiotic choice. Thirty-day telephone follow-up determined outcomes. Data regarding demographics, outcomes, and costs were analyzed. RESULTS: Forty-four patients received mandatory ID consultation, 39 (88.6%) of whom had some change in antibiotic recommendations. Seventeen (38.6%) were discharged on oral antibiotics, 1 (2.3%) had antibiotics discontinued, 13 (29.6%) had a change in parenteral antibiotic, 5 (11.4%) had a change in antibiotic dose, and 3 (6.8%) had a change in antibiotic duration. Follow-up demonstrated a single rehospitalization for unrelated issues. The total cost savings were 33,667.00 US dollars, approximately 760.00 US dollars per patient. Charges of consults were approximately 11,970.00 US dollars, still resulting in savings of close to 21,700.00 US dollars, or almost 500.00 US dollars per patient. CONCLUSIONS: Mandatory ID consultation resulted in substantial cost savings and excellent outcomes.     

Infectious disease consultations and antibiotic usage in a Turkish university hospital.

OBJECTIVES: The aim of this study was to investigate the various features of infectious disease (ID) consultations and the usage of antibiotics in a Turkish university hospital. METHODS: A total of 395 consultation requests were recorded during a three-year period. RESULTS: The departments most frequently requesting the consultation services of the ID department were Orthopedics (29.6%), Neurology (18.5%), Cardiology (11.8%) and Internal Medicine (10.4%). The main reasons were for diagnosis of unexplained fever (42.3%) and for antibiotic modification according to culture results (18%). Diagnoses made by the ID consultant were pneumonia (16.7%), urinary tract infections (9.3%), bone and joint prosthesis infections (9.1%) and in 15.7% of the investigated patients, no infectious focus was determined. It was recognized that the use of antibiotics had already been initiated in the great majority of patients (67.1%) before the consultation request. While the current therapy was changed in 57.4% of these patients, antibiotics were not necessary for 9.8%. CONCLUSIONS: Since the most common diagnoses were respiratory and urinary tract or bone and joint prosthesis infections, the ID specialists should have detailed knowledge of these problems. Usage of antibiotics without ID consultation was prevalent, therefore a continuous educational program is a necessity for healthcare workers in the hospital.     

Whither infectious diseases consultations? Analysis of 14,005 consultations from a 5-year period.

During a 5-year period, data from all infectious disease (ID) consultations were recorded in a computerized database, which included 9068 new and 4937 additional consultations. The purpose of these 14,005 consultations was therapy (for 58%), diagnosis (for 13%), both (for 24%), and prophylaxis (for 4%); 51% were performed at the bedside, and the remainder were by discussion (19%) or telephone (30%). Recommendations included the following: initiation, change, or discontinuation of antibiotics (in 46%); performance of diagnostic tests (in 20%) or surgical procedures (in 1%); prophylaxis (in 3%); or no change (in 29%). Analysis of new versus additional consultations revealed significant differences. A new ID consultation was given at a rate of 6.0 consultations per 100 hospitalized patients; the rate per department correlated with the expenditure on antimicrobials per patient admission. During the study period, expenditure on antimicrobials per admission steadily decreased, from $44 in 1995 to $30 in 1999, a 35% reduction. In conclusion, analysis of data from ID consultations enables the ID service to evaluate its activity and to direct efforts to departments with high rates of nosocomial infections, antimicrobial resistance, and/or antimicrobial use.     

The effectiveness of a consultation: Compliance with initial recommendations

To identify the attributes of an effective consultation, 202 general medicine consultations were analyzed to assess the extent of compliance with the consultant's initial recommendations. The overall compliance rate was 77 percent. Compliance decreased as the number of recommendations increased. The consultant made more recommendations among patients who had more complex and more severe illnesses. Although compliance did increase significantly in severely ill patients (p < 0.01), with each severity level, compliance was higher when five or fewer recommendations were made. In fact, compliance decreased from 96 percent in severely ill patients with small consultation lists to 79 percent in those with large lists. Compliance was greatest with recommendations involving medications and least with those requiring direct physician and nursing action. Multivariate analysis confirmed that clinical severity of the patients' illnesses and the type and number of recommendations were all predictors of compliance. To promote overall compliance, consultants should limit the total number of recommendations in their initial consultation to five or fewer, focusing on issues central to current patient care. This is especially true in severely ill patients. Since recommendations that must be implemented by physicians or nurses have a lower compliance rate, consultants must carefully follow up those requests.     

Infectious diseases consultations can make the difference: a brief review and a plea for more infectious diseases specialists in Germany

Trained infectious diseases (ID) specialists are an integral part of inpatient and outpatient care in many countries, however, these specialized services are established only in selected tertiary care hospitals in Germany. This review summarises studies that addressed the impact of ID consultation services on patient care and outcome. Extensive data for a clinical benefit is available in the context of Staphylococcus aureus bacteremia (SAB), in which in-hospital or 30-day mortality was significantly reduced by 40–50 % in patients evaluated and treated in cooperation with ID consultants. This effect was associated with improved adherence to quality-of-care standards. Moreover, newer studies show a reduced length of hospital stay due to ID consultations, especially if patients are evaluated early in the course of their hospital stay. Of note, informal consultations do not seem to be equivalent to a formal ID consultation with bedside patient evaluation. Studies in other patient groups (solid organ transplant recipients or intensive care unit patients) or in the context of other infections (infective endocarditis, pneumonia, other bloodstream infections) also revealed positive effects of ID consultations.Higher rates of appropriate empirical and targeted antimicrobial treatments and de-escalation strategies due to successful pathogen identification were documented. These modifications resulted in lower treatment costs and decreased antimicrobial resistance development. Although there are methodological limitations in single studies, we consider the consistent and reproducible positive effects of ID consultations shown in studies in different countries and health care systems as convincing evidence for improved quality-of-care and treatment outcomes in patients with infectious diseases. Thus, we strongly recommend efforts to establish significantly more ID consultation services in hospitals in Germany.     

Infectious diseases consultations from general internal medicine physicians in Japan: A descriptive single-center study

In Japan, general internal medicine (GIM) physicians must be aware of frequently encountered infections because of the shortage of infectious disease (ID) specialists. However, there are currently no epidemiological data on this subject. This study aimed to describe the frequency and pattern of ID consultations requested by GIM physicians in Japan. This is a 3-year retrospective review of the ID consultations requested by GIM physicians in Japan at a community-based acute tertiary care teaching hospital in Tokyo from April 2018 to March 2021. Demographic data, such as reasons for consultation, causative organism, and final diagnoses, were collected. During the study period, ID consultations were requested by GIM physicians 128 times. The incidence rates of bacteremia and 30-day mortality were 65.6% (n = 84) and 3.1% (n = 4), respectively. The most common diagnostic classifications after ID consultation were bone/joint (24.2%, n = 31), respiratory (17.7%, n = 22), and cardiovascular infections (12.5%, n = 16). The most common final diagnoses were bacteremia (11.7%, n = 15), infective endocarditis (9.4%, n = 12), and vertebral osteomyelitis (7.8%, n = 10). This is the first study to describe the ID consultation cases requested by GIM physicians in Japan in a community-based acute tertiary care teaching hospital. Despite the shortage of ID specialists, GIM physicians covered a wide range of IDs, including bone/joint infections and infectious endocarditis, which require long-term care. ID and GIM physicians, including hospitalists, should cooperate to promote the quality of care and clinical management. Future multi-center studies with large numbers of clinical cases are needed to determine the ID clinical knowledge required by GIM physicians in Japan.     

The preoperative consultation. Response to internists' recommendations

Preoperative consultations are frequently performed; however, little is known about the way requesters respond to the recommendations offered. For this reason, 90 consecutive preoperative consultations, performed by a general medical unit, were reviewed and compared with 66 consecutive nonpreoperative consultations, performed by the same unit during the same period. Analysis disclosed that recommendations made during preoperative consultation were often not followed and were less likely to be followed than were those made during nonpreoperative consultation (53.9% v 68.9%). Controlling for the type of consultative advice offered and for the type of surgical service requesting the consultation did not alter this relationship. These results highlight the particular importance of consultant follow-up for recommendations made during preoperative consultations.     

Antibióticos y el factor tiempo en la infección en urgencias

Infectious diseases, besides being a major cause of mortality in developing countries, are one of the main reasons for consultation in emergency medicine. In the last few years, there have been numerous published studies on the importance of starting antibiotic treatment at an early stage in the Emergency Department. However, this issue is of great controversy, owing to some contradictory studies as well as the implications this may have on the pressure of the patient care. This review is presents a summary of the scientific evidence published in this regard, and makes some recommendations based on this published evidence to improve the initial management of patients with an infection; a question of great importance as it can reduce mortality in some specific situations.     

Preoperative medical consultations in a community hospital

To evaluate the practice of consultations in the community hospital, chart reviews and consultant/surgeon interviews were conducted for 85 consecutive medical preoperative consultations for patients discharged from the Surgical Service. In 78 cases (92%) the authors agreed with the need or reason for the preoperative consultation; the majority were required for the management of chronic medical problems. Continuity of care was considered important by surgeons and consultants. Verbal communication was common, particularly from surgeon to consultant. Brief response time, specific recommendations, focused evaluations, and physician satisfaction with the existing system were the rule. However, 23 preoperative consultations (27%) were judged to be deficient. Compliance with recommendations was high (95%) but other measures of consultation effect were low.     

The importance of specialist treatment, treatment satisfaction and diabetes education for the compliance of subjects with type 2 diabetes - results from a population-based survey.

AIMS: This study aims to investigate the degree to which subjects with type 2 diabetes comply with treatment recommendations concerning diet, physical exercise and self-care, the consistency of compliance across different treatment areas, and the association of compliance with individual characteristics of patients and their medical treatment. METHODS: The sample consists of 345 type 2 diabetes patients who had been drawn from two population-based surveys (MONICA) and from a myocardial infarction registry in Southern Germany, and who have participated in a survey in 1997/98. Data were collected by interviews, questionnaires and medical exams. Pearson correlation and logistic regression analysis were applied to test the relationships. A compliance score was established by adding up the components of the treatment regimen. RESULTS: Only one fifth of the subjects with type 2 diabetes showed good compliance in terms of the applied score. Compliance was highest in weight measuring and foot care, and poorest in following exercise recommendations, glucose testing, and recording the results. Overall, weak correlations were found between the components of the treatment regimen. Participation in diabetes education, regular consultation of physicians specialized in diabetes care, age (<70 years), and satisfaction with treatment were all associated with better compliance. CONCLUSIONS: Correlation between the different components of compliance behaviour was low, indicating that compliance should not be measured by one component only. As compliance with the treatment recommendations was poor, education programs for type 2 diabetic subjects should be propagated and the cooperation with diabetes specialists should be promoted.     

The use of CRP tests in patients with respiratory tract infections in primary care in Sweden can be questioned

A diagnosis-antibiotic prescribing study was performed in 5 counties in Sweden during 1 week in November in 2000 and 2002 respectively. As a part of the study, the use and results of C-reactive protein (CRP) tests in relation to duration of symptoms and antibiotic prescribing in 6778 patients assigned a diagnosis of respiratory tract infections were analysed. In almost half (42%) of the patients, a CRP test was performed. The majority of CRP tests (69%) were performed in patients assigned diagnosis upper respiratory tract infection, where the test is not recommended. Overall, there was a minor decrease in antibiotic prescribing when CRP was used (41%), in comparison to 44% of the patients where no CRP was performed (p < 0.01). Patients assigned diagnoses implying a bacterial aetiology were prescribed antibiotics irrespective of result of CRP or length of symptoms before consultation. For patients assigned viral diagnoses, antibiotic prescribing increased with increasing duration of symptoms and increasing value of CRP. The use of CRP decreased antibiotic prescribing in patients assigned to viral diagnoses and with longstanding symptoms (p < 0.001). However, 59% of the patients assigned viral diagnoses with CRP > or = 25 received antibiotics, which seems to indicate a misinterpretation of CRP and a non-optimal use of antibiotics.     

Discrepancies between patient and professionals recall and perception of an outpatient consultation.

AIMS: To explore the degree of agreement between patient and health care professional's perceptions of consultations. METHODS: Immediately after 141 dietitian/nurse specialist consultations, patients and professional's completed the Health Care Climate questionnaire (HCC), Medical Interview Satisfaction Scale (MISS) and the Treatment Self-Regulation Questionnaire (TSRQ) In addition, both parties were asked about any key points or issues discussed in the consultation; any decisions that were made about their diabetes treatment today; any goals that were set as a result of today's consultation. RESULTS: Patient and professional's scores on the HCC and MISS were not correlated (r=0.3 and 0.16). Patient and professionals disagreed on the issues discussed 19.6% of the time, on the decisions made 20.7% of the time and goals set 44.3% of the time. More autonomy support in the consultation was associated with greater autonomous motivation for self-care (r=0.31; P<0.001) more controlled motivation was associated with less agreement on issues discussed and goals set (r=-0.20; r= -0.24; P<0.05). CONCLUSION: There is significant disagreement between patients and professionals perceptions and recollection of the content of consultations. Professional's communications skills need to be developed to ensure these discrepancies are minimized. Skills to provide greater autonomy support in the consultation would help to enhance this process and improve outcomes.     

Recommendations for prevention of bacterial endocarditis: compliance by dental general practitioners

Telephone interviews were conducted with a national sample of general practice dentists (n = 460). Clinical vignettes were used to test clinicians' knowledge of, and compliance with, the 1984 American Heart Association (AHA) recommendations for prevention of bacterial endocarditis. Analyses of the data document a relatively low level of knowledge of correct indications and regimens for antibiotic prophylaxis to prevent endocarditis. Respondents were unsure, and often incorrect, about the relationship between a variety of cardiac conditions and potential risk for endocarditis. Compliance with the guidelines for proper dosage and timing of antibiotics was also problematic. Those clinicians who had a better understanding of patient risk factors and the principles underlying the AHA recommendations were more likely to follow them, as were practitioners who kept a copy of the recommendations in the office. The findings are significant in view of previous suggestions that use of inappropriate antibiotic regimens may predispose to adverse outcomes.     

Cost analysis of antibiotic prophylaxis for PEG

BACKGROUND: There are conflicting recommendations regarding the prophylactic use of antibiotics in patients undergoing placement of percutaneous endoscopic gastrostomy tubes. The purpose of this decision analysis was to assess the cost-effectiveness of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. METHODS: A decision tree was modeled using the data of 7 published prospective placebo-controlled trials. Infectious complications were classified as grade I (requiring local care), grade II (requiring intravenous antibiotics), or grade III (requiring surgery). Medication costs were estimated from the United States average wholesale prices of the 1998 Red Book. Physician and facility costs were estimated based on the 1998 Medicare costs. A one-way sensitivity analysis was performed by varying the probability rates of the complications associated with percutaneous endoscopic gastrostomy and the costs of their treatment. RESULTS: The average cost of prophylactic antibiotics was $13.10. Antibiotic prophylaxis led to expected cost savings of $76.72 per percutaneous endoscopic gastrostomy. A sensitivity analysis suggested that antibiotic prophylaxis for percutaneous endoscopic gastrostomy was the preferred strategy unless the average probability of grade III complications dropped below an improbably low threshold value of 0.09%. CONCLUSION: Antibiotic prophylaxis in percutaneous endoscopic gastrostomy is a cost-effective strategy.     

Formal Adult Infectious Disease OutpatientConsultations: A Retrospective 6-Year Survey

Background  The field of outpatient infectious disease (ID) consultations is expanding. Surprisingly, limited data are available regarding the scope of formal, adult, outpatient ID consultations. Methods  The computerized records of all adult outpatient ID consultations conducted by a single ID expert over the years 2001–2007 were retrospectively analyzed. Demographic, clinical and management characteristics were studied. Results  We identified 619 eligible cases, mostly women (61.4%). The mean age (± SD) was 39 ± 15.5 years, and each patient had 1.3 ± 0.7 visits on average. In 12% of the cases, symptoms have been fluctuating for ≥ 1 year. Most of the cases (54.3%) have been referred for the purpose of management rather than diagnostics. Largest areas leading to ID consultation were post-travel medical conditions (15.5%) and pregnancy-related infections (11%); specific leading categories were viral infections (17.3%), skin and soft tissue syndromes (15.2%) and gastrointestinal syndromes (7.6%). Recurrent, well-characterized infections plus ill-defined syndromes constituted a substantial part of all referrals. Newly discovered findings were elicited in the medical history and physical examination in 3.7% and 2.7% of cases, respectively. Conclusions  Formal outpatient ID consultations have unique aspects, which differ from “traditional” inpatient consultations. The field offers exciting medical research possibilities and new themes for healthcare executives.     

Northwick Park Infection Consultation Service. Part I. The aims and operation of the service and the general distribution of infection identified by the service between September 1987 and July 1990 [see comment

The Northwick Park Infection Consultation Service (ICS) is a collaborative service operated by the departments of Medical Microbiology and Infectious Diseases where personnel and skills are combined. Its aim is to improve the availability and effectiveness of consultation for infection-related problems. This paper sets out the framework for establishing an ICS and also details the general distribution of infection identified by the Northwick Park ICS in a study carried out between September 1987 and July 1990. Part II assesses the contribution that the ICS made to the management of infection. One thousand and thirty-eight (1038) patients were seen on the ICS. Seventy-five per cent (776) were judged to be infected and in 691 this was a probable or certain diagnosis. Skin and subcutaneous tissue, respiratory tract, and genito-urinary tract infections accounted for 64% of the total. Eighty-seven per cent of infections required treatment with intravenous antibiotics, 22% were associated with concomitant bacteraemia, and 2.7% of patients died as a direct result of their infection. Sixty-four per cent of consultations were unsolicited and arose from laboratory results or the clinical information on the form accompanying the specimen: over one quarter were initiated before results were available. These infections were no different in either severity or nature from those identified by solicited requests to either department. Fifty-three per cent of consultations had a moderate to high clinical component. The results emphasise the importance of infection in hospitals and highlight the advantages of a collaborative approach from the departments of Medical Microbiology and Infectious Diseases.