The ID List 10 Things Hospitalists
Should Know About Infectious Diseases
Thomas R. Collins; John Bartlett, MD; Robert Orenstein Do
Posted: 04/23/2012; The Hospitalist. 2012;16(4):1, 34-36. ©
2012 John Wiley & Sons, Inc.
Abstract and Introduction
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."
References
1.
Kim SH, Kim KH, Kim HB, et al.
Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus
aureus bacteremia. Antimicrob Agents Chemother. 2008;52(1):192–197.
2.
González C, Rubio M, Romero-Vivas J,
González M, Picazo JJ.. Bacteremic pneumonia due to Staphylococcus aureus:
A comparison of disease caused by methicillin-resistant and
methicillin-susceptible organisms. Clin Infect Dis.
1999;29(5):1171–1177.
3.
Stryjewski ME, Szczech LA, Benjamin
DK Jr., et al. Use of vancomycin or first-generation cephalosporins for the
treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus
aureus bacteremia. Clin Infect Dis. 2007;44(2):190–196.
The Hospitalist. 2012;16(4):1,
34-36. © 2012 John Wiley & Sons, Inc.
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