Abstract
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.
Introduction
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
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