Monday, May 7, 2012
USA - The ID List 10 Things Hospitalists Should Know About Infectious Diseases
The Hospitalist surveyed half a dozen infectious disease (ID) experts—some of whom also have experience as hospitalists—what they would tell a roomful of hospitalists who were curious about ID. Based on those discussions, we offer 10 tips that should help hospitalists treat their patients more effectively.
Hospitalists routinely care for patients with infections, or symptoms of infections, or suspected infections that might not even be infections at all. Many times, hospitalists have more than one treatment option. So which is the best to use? Is there a better option than the therapy that first comes to mind? What about that new antibiotic out there—is it really worth it?
All the while, hospitalists who want to practice conscientious medicine have to be careful they don't overuse broad-spectrum antibiotics so that bugs' resistance to the drugs is not speeded up unnecessarily.
In short, infectious diseases can be dicey terrain.
1 Prepare for the reality that the availability of new drugs is shrinking because of antibiotic resistance.
That grim fact might be cause for hospitalists to seek help from ID specialists at their hospitals, says John Bartlett, MD, professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore and founding director of the Center for Civilian Biodefense Strategies. The FDA has approved just two new drugs for major infections in the last five years, he says.
"The FDA faucet is really dry," says Dr. Bartlett, a world-renowned speaker on ID topics and a frequent speaker at SHM annual meetings. "There are no new antibiotics to speak of, no new antibiotics for resistant bacteria. And there's not likely to be any for several years. So [hospitalists] are going to find themselves painted in a corner, and they'll probably have to ask for help."
Leland Allen, MD, an infectious-disease specialist at Shelby Baptist Medical Center near Birmingham, Ala., who worked as a hospitalist for nine years, says hospitalists should not hesitate to seek assistance. "It's never a burden to do a consult," he says. "The reality is that it's a lot less work if you consult early rather than waiting until the patient is sick."
Dr. Bartlett says hospitalists should brush up on the use of colistin, a drug developed in 1959 that has been little used and requires careful dosing to avoid toxicity. "We're finding more and more patients that that's the only thing we've got for them," he says.
2 Familiarize yourself with new technology for identifying bugs.
"Mass spectrometers have been used for identifying microorganisms through a computerized database, and these units are just starting to become available to large health centers," says Robert Orenstein, DO, associate professor of medicine in infectious diseases at the Mayo Clinic in Phoenix. "This allows you potentially to identify some of these microorganisms almost immediately— if they're in the database, which is the key."
Dr. Bartlett says it's important for hospitalists to pay attention to the "dramatic changes" in the technology, including the emergence of the ppolymerase chain reaction (PCR) test.
"They have to be aware that there are methods that are very sophisticated and very sensitive and specific," he says, adding that hospitalists have to keep up with what the methods can measure and what their limitations are.
"If you're going to practice 2012 medicine and infectious disease, you've got to know about the rapid movement in microbiology," he says. "It's very fast."
3 Beware the nuances of Staphylococcus aureus treatment.
James Pile, MD, FACP, SFHM, an ID specialist and interim director of hospital medicine at Case Western Reserve University/MetroHealth Medical Center in Cleveland, says an important tidbit regarding S. aureus is that when it's isolated from blood culture, it should never be considered a contaminant; it's the real thing.
"Any of us that have practiced for any length of time can certainly recite tales of bad outcomes when even transient S. aureus bacteremia was ignored or considered a contaminant, and then patients many times were subsequently readmitted with serious complications," he says.
He also notes that beta-lactam antibiotics continue to be the clear choice for serious methicillin-sensitive S. aureus (MSSA) infections. He says doctors should not give in to the temptation to treat these patients with vancomycin, as studies have shown better outcomes and lower mortality with beta-lactams.[1,2,3]
As for methicillin-resistant S. aureus (MRSA), vancomycin—long the "workhorse" in the fight against MRSA—might remain the best choice despite a series of newer, and more costly, drugs. The reason: a lack of persuasive data that show the new therapies are better, he notes.
Dr. Bartlett cautions that because of the growing resistance of MRSA, the rules for vancomycin use for MRSA are "totally new."
"They have to know the rules," he adds.
4 It's important to continue to keep Clostridium difficile on your radar— it's still a top threat.
Neil Gupta, MD, a former hospitalist who works as an epidemic intelligence service officer with Atlanta-based Centers for Disease Control and Prevention (CDC), emphasizes glove use and, if possible, immediately curtailing the use of other antibiotics for patients with suspected C. diff.
"Glove use has been proven to be one of the most effective measures at reducing transmission of C. diff," he says, "and treatment for C. diff is less effective if a patient is on other antimicrobials."
Dr. Orenstein says hospitalists should be familiar with the evidence-based guidelines for C. diff treatment—the use of metronidazole for mild to moderate cases, or vancomycin for severe cases.
"The practice that we see is all over the board," Dr. Orenstein notes.
Dr. Pile offered another C. diff tip: If patients who are hospitalized or were recently hospitalized display an unexplained, marked elevation of their white blood cell count, it's important to think about the possibility of a C. diff infection due to the organism's predilection for causing striking leukocytosis. On occasion, this might precede, or occur in the absence of, diarrhea.
5 Take out unnecessary IV lines.
David Chansolme, MD, medical director of infection control for Integra Southwest Medical Center in Oklahoma City and a member of the Clinical Affairs Committee with the Infectious Diseases Society of America, explains that all too often the lines will be kept in during the transport of a patient to a skilled-nursing facility. It's a practice that, he says, comes with a big risk.
"Leaving a line in just for blood draws is probably not OK," Dr. Chansolme says. "Nowadays, you're just seeing way too many of those infections."
Patients headed for a skilled-nursing facility are at an especially high risk because there is such a high rate of multidrug-resistant organisms, he says.
6 Be aware of urinary catheters, and use appropriate therapy for catheter-associated urinary tract infections (CAUTIs).
Physicians often are unaware when patients have urinary catheters, Dr. Gupta says, in part because they are frequently placed in the ED and documentation can be missing.
"It's important to keep this on [hospitalists'] radar whenever they see a patient, so they can remember to remove these as soon as they can, when they're no longer needed," Dr. Gupta says, adding that timely removal can prevent an unnecessary risk of CAUTIs.
He also cautions that a third of antimicrobials used to treat CAUTIs are inappropriately aimed at treating asymptomatic bacteriuria, and hospitalists have to be sure that there truly is an infection.
7 A urine culture without a simultaneous urine analysis is practically worthless.
Once a catheter has been in for three or four days, most patients will have "all kinds of bacteria and fungus growing in their urine," Dr. Allen says.
"A urinalysis lets you assess for the presence of pyuria or other signs of urinary tract inflammation," he says. "That's how you determine whether a germ growing in the urine is a colonizer or a true pathogen."
8 Bactrim does not treat strep.
"If you have somebody that maybe has been in the hospital on vancomycin because they have cellulitis and are getting better and ready to go home, if you don't know if that cellulitis is staph or strep, be careful about the agent that you choose to send them home on," Dr. Chansolme says. "Make sure it has activity against Streptococcus."
He frequently sees patients de-escalated to the wrong drug—trimethoprim/sulfamethoxazole (Bactrim).
"They'll go home, and a couple days later they'll be back because it was in fact a strep infection, not a staph infection," he says. "If you're not sure, it's probably better to use something like doxycycline or clindamycin, or something along those lines, that will treat both."
9 Be sure to take proper precautions when it comes to norovirus.
Winter is the time of year to be most concerned about norovirus outbreaks. It's also important to realize it affects people of all ages, is especially common to closed or semi-closed communities (i.e. hospitals, long-term care facilities, cruise ships), and spreads very rapidly either by person-to-person transmission or contaminated food.
"It's really important to understand that if a patient is suspected of having norovirus, that patient should be placed in contact precautions immediately, and preferably, when possible, in a single-occupancy room," Dr. Gupta says. "If a healthcare provider becomes ill with sudden nausea, vomiting, or diarrhea, that's consistent with possible norovirus. They should stay home for a minimum of 48 hours after symptom resolution before coming back to work."
And because norovirus is so contagious, quick action has to be taken if such an outbreak is suspected.
"If there's any concern at all in your facility," he says, "get in touch with an infection prevention committee to make sue all appropriate measures are taken."
10 Never swab a decubitus ulcer unless that ulcer is clearly infected.
Dr. Allen says it's important to know that it doesn't make sense to culture an ulcer that doesn't have any signs of infection, such as pus or redness—although he sees it happen routinely.
"Just because a patient has a bedsore doesn't mean it's infected," Dr. Allen says. "Usually, they're not infected. But they're going to have a dozen different germs growing in them."
Culturing and treatment without signs of infection, he says, often leads to "inappropriate antibiotic use and probably increased length of stay."
Thomas R. Collins; John Bartlett, MD; Robert Orenstein Do