The Top 10 Things ID Specialists Wish Every Hospitalist Knew

In my experience, hospitalists usually have a greater knowledge of antibiotics and treatment of infections than other non-infectious disease (ID) practitioners who manage hospital patients. But that doesn’t stop ID physicians from wanting to make suggestions. The following list is not meant to be all-inclusive, but it does reflect an informal poll of my colleagues at a tertiary care medical center. Any opinions are of course my own, and naturally are evidenced based. There is an old joke that if you ask two ID doctors a question you get three answers. Having said that, I believe that there is a good consensus on these issues.

1. Beta-lactam/beta-lactamase inhibitors have excellent anaerobic coverage.

Beta-lactam/beta-lactamase inhibitors such as ampicillin/sulbactam and piperacillin/tazobactam have excellent anaerobic coverage. When treating suspected or proven anaerobic infections with these drugs, addition of other agents such as metronidazole and clindamycin to cover anaerobic infections is not necessary (1). Quite often we see patients treated with ampicillin/sulbactam and metronidazole or piperacillin/tazobactam and metronidazole, which is not necessary and potentially exposes the patient to additional drug toxicities. “Unasyn and Flagyl” for suspected intra-abdominal infections provides unnecessary double coverage for anaerobes, while providing suboptimal coverage for gram-negative rods due to increasing resistance to ampicillin/sulbactam among gram-negative aerobes.

2. Staphylococcus aureus bacteremia “always” gets at least 2 weeks of IV antibiotics.

Clinicians managing patients who have blood cultures positive for Staphylococcus aureus should always think about whether the patient has a deep-seated source such as cardiac or bone, and treat accordingly. But even patients with a self-limited bacteremia related to an intravenous catheter or other easily removable source of infection should get at least 2 weeks of antibiotics (2). One of the goals of treating S. aureus bacteremia is to prevent metastatic infection. Patients with line-related infections may have rapid clinical improvement and resolve the bacteremia quickly, but they are at high risk for relapse with bone, joint, or cardiac infection if the initial antimicrobial course is inadequate. At least once every year or 2 at our teaching hospitals we see a patient who is given a very short course of antibiotics for S. aureus bacteremia related to an intravenous catheter who returns a month or two later with relapse in the spine or in other equally serious sites of infection. It is believed that more aggressive initial antimicrobial therapy can prevent metastatic infections. A frequently employed strategy in evaluating patients with S. aureus bacteremia is to complete a transesophageal echocardiogram to rule out cardiac involvement. If there is no cardiac involvement and other deep seated source such as bone or joint are not suspected, 2 weeks of intravenous antibiotics are generally adequate. In the setting of cardiac involvement or deep-seated involvement in bone or joints, 4–6 weeks of antibiotics are required. Patients with staphylococcal bacteremia who do not have a known source of infection should almost always be treated for 4–6 weeks. And, of course, there is the usual caveat: Oral antibiotics with excellent oral bioavailability such as linezolid can be used as switch therapy to complete a 2-week course in some cases. But the default approach would be to treat all S. aureus bacteremias with at least 2 weeks of intravenous antibiotics.

3. Staphylococcus aureus in the urine should almost always prompt a search for another site of infection.

Patients who have Foley catheters or are status post-genitourinary procedures may develop primary S. aureus urinary tract infection, but it is unusual for patients without history of genitourinary manipulation to present with S. aureus as a cause of urinary tract infection. In patients with no predisposing factors for S. aureus urinary infection, isolation of the organism in the urine should always prompt an evaluation for another site of infection such as bone, joint, or endovascular. Patients with known or suspected S. aureus urinary tract infection should have blood cultures drawn prior to the initiation of antibiotics to detect occult bacteremias. It is not unusual on our Infectious Disease Consult Service to see a patient who is suspected of having a S. aureus UTI that is later shown after consultation and investigation to have S. aureus endocarditis without other obvious manifestations, or another deep-seated infection such as spinal osteomyelitis or epidural abscess.

4. Stool assays for Clostridium difficile lack a high degree of sensitivity.

North America is experiencing an explosion in illness related to Clostridium difficile (primarily C. difficile associated diarrhea, or CDAD) (3). C. difficile is most often a nosocomial infection, and CDAD has become a very common disease in patients hospitalized for any length of time who are given broad-spectrum antibiotics. Hospitalization is the “perfect storm” for CDAD. C. difficile spores exist in the hospital environment and are ingested by patients on broad-spectrum antibiotics that inhibit the normal flora, creating the perfect environment for C. difficile to flourish. The assays to detect C. difficile toxins in the stool are often not highly sensitive; under the best of circumstances the techniques used by most hospital labs will produce a false-negative result 10–20% of the time (4). Not all labs detect all toxin types, and not all kits are highly efficient for detecting toxins. Patients in whom there is a strong suspicion for CDAD should be treated even in the face of negative toxin assays unless there is another likely source of diarrhea.

5. Hospitalized patients who develop diarrhea after admission almost never have enteric infections other than CDAD.

Patients who develop diarrhea after being in the hospital 1 or 2 days almost never have infection with Salmonella, Campylobacter, Entamoeba histolytica, or Giardia sp. It is not uncommon to see hospitalized patients who develop diarrhea after several days in the hospital with shotgun orders for “SSYC and O&P.” Unless there is a history of immunosupression or risk factors for enteric infection such as international travel, these tests are almost always unnecessary (5). 6. The most common cause of leukocytosis of unknown etiology in hospitalized patients is CDAD. There is something about the pathogenesis of CDAD that produces a leukemoid reaction much more often than other infections do. It is not unusual to see white blood cell counts of 30,000 with CDAD, and counts of 50,000 and higher in patients with CDAD are not rare. Patients who develop leukocytosis in the hospital while on antibiotics, or who present from long-term care facilities with marked leukocytosis and recent antibiotic exposure, have a high pretest probability of having CDAD (6). In this setting, the higher the white count, the more likely the patient has CDAD.

6. Blood cultures should always be obtained before parenteral antibiotics are given for a febrile illness.

Patients who are given broad-spectrum antibiotics have 1 opportunity to have interpretable blood cultures obtained: before antibiotics are administered. Once patients are given broad-spectrum antibiotics, blood cultures have a very limited value in diagnosing infections that might not be initially suspected on admission. A common example in our hospital is a patient presenting with pneumonia. About a third of the patients who come through the emergency room with a diagnosis of community-acquired pneumonia end up having another diagnosis. Often the alternative diagnosis is suspected based on blood cultures obtained prior to the patient receiving broad-spectrum antibiotics in the emergency room. In the last 3 months we have seen patients with liver abscesses, endocarditis, and osteomyelitis initially felt to have community-acquired pneumonia whose blood cultures initiated prior to antibiotic therapy revealed a pathogen that caused a search for an alternative source of infection. The vast majority of patients only need 2 blood cultures from 2 sites 20 minutes apart before initiation of antibiotic therapy. Patients in whom common skin contaminants may easily be interpreted as pathogens (such as patients with prosthetic heart valves) should have 3 sets of blood cultures to aid in the interpretation of cultures that are positive for skin contaminants such as coagulase negative staph.

7. In diabetics without foot ulcers, cellulitis is most often due to Streptococcus and occasionally to Staphylococcus species.

Diabetic patients who have infections related to foot ulcers or ischemic lesions require broad-spectrum antimicrobial therapy active against anaerobes, gram-positives, and gram-negatives. However, diabetic patients who are not critically ill who are admitted with a clinical picture typical for cellulitis tend to be infected with the same pathogens as non-diabetic patients. We frequently encounter diabetic patients who present with a clinical picture of an uncomplicated cellulitis without ulcers or other lower-extremity lesions and are treated with broader-spectrum antimicrobial therapy than is needed for cellulitis. Broader therapy is often more expensive, and it puts patients at risk for more adverse effects such as CDAD. The great majority of patients with cellulitis have infection with group A strep and other streptococci, and less often S. aureus. Cellulitis due to anaerobes and gram-negative organisms in the absence of foot ulcers or similar lesions is distinctly unusual.

Comments

  1. Michele G. says

    Good job! Wish I had seen this years earlier. At our hospital in Ireland, we could be implementing four of the items you have listed. Will take this back to my team. (And yes, we enjoy working with you, too! I used to be annoyed as an intern being told to “call Micro and see what they think” when it seemed so obvious what the answer was, but Micro over the past few years has saved me from making several silly decisions.)

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