Despite the widespread availability of potent anti-infective agents, infectious diseases remain formidable and common problems in hospitalized patients. In this issue of The Hospitalist, hospitalists and infectious disease specialists provide state-of-the-art reviews of common infectious disease syndromes encountered in hospital medicine. This should be required reading for hospitalists, given the severity of illness of many patients with these syndromes, and the rapidly evolving developments in optimal diagnosis and management in many of these areas.
Hospitalists and infectious disease practitioners share similar challenges and should be natural allies in improving patient care. To name a few, these challenges include the prompt recognition and management of new and emerging infectious diseases; the rising incidence of drug-resistant pathogens; the prevention, prompt recognition, and effective management of nosocomial and opportunistic infections in hospitalized patients, including outbreaks; the implementation of clinical practice guidelines for common infectious disease problems; and the vaccination of high-risk hospitalized patients.
New and emerging infectious diseases have been recognized with increasing frequency, and hospitalists are among those physicians most likely to encounter them. In the past two years alone, these have included SARS (1), monkeypox (2), tanapox (3), and American Boutonneuse fever (4). Drug-resistant pathogens have become increasingly common. Methicillin-resistant Staphylococcus aureus (MRSA) now accounts for more than 50% of Staphylococcus aureus isolates in many hospitals. Until recently, MRSA has afflicted mainly hospitalized patients or those with significant underlying comorbidities. Recent reports, however, have described MRSA in previously healthy patients admitted from the community (5,6) Even more ominously, isolates of Staphylococcus aureus with intermediate or high-level resistance to vancomycin have been reported (7,8).
Drug-resistant Streptococcus pneumoniae is common in many parts of the United States; many isolates are resistant to multiple common antibiotics, and fluoroquinolone resistance, though still uncommon, has been reported (9,10). Vancomycin-resistant enterococci have emerged over the past decade and now account for up to 15% of enterococcal isolates in many centers. Macrolide-resistance in Treponema pallidum was recently described (11). The emergence of drug-resistant pathogens has important implications for hospitalists, who are typically at the front line in choosing empiric or pathogen-specific antimicrobial therapy for hospitalized patients. Knowledge about local trends in antimicrobial resistance is essential for making informed antibiotic selections, and prevention of spread of these organisms within hospitals is crucial.
How have hospitalists partnered with infectious disease specialists in tackling these problems? Surprisingly, very little has been written. In our review of the literature we were able to identify only 3 studies addressing the role of hospitalists and infectious disease physicians in the management of infectious diseases (12-14). Reddy et al. compared the impact of a clinical practice guideline introduced at the University of California San Francisco Moffitt-Long Hospital in 1996 with that of a hospitalist-based reorganization of their medical service in the management of patients with community-acquired pneumonia (CAP) (12). Following implementation of the guideline, average cost per case and length of stay declined similarly among patients cared for by hospitalists versus those cared for by attending physicians on the traditional medical service. Mortality remained unchanged despite shorter length of stay, and readmission rates fell. However, hospitalists achieved statistically greater reductions in cost per case and length of stay for all other diagnoses compared with their traditional attending counterparts. This study therefore concluded that the implementation of a clinical practice guideline was the key driver in improving resource utilization in hospitalized patients with CAP, rather than physician model of care.
In a similar study, Rifkin et al. compared outcomes and resource utilization in hospitalized patients with CAP at Long Island Jewish Medical Center cared for by hospitalists (185 patients) versus primary care physicians (270 patients) (13). No local clinical practice guideline was in place, although appropriateness of therapy was evaluated based upon guidelines disseminated by the American Thoracic Society and the Infectious Disease Society of America at the time. Compared with hospitalists, primary care physicians obtained more subspecialty consultations and administered antibiotics in a more timely fashion. Nevertheless, hospitalist care was associated with shorter length of stay, lower cost per case, more rapid transition from parenteral to oral antibiotic therapy, and improved survival. Hospitalist patients were more likely to be discharged with an unstable vital sign, but 15- and 30-day readmission rates were similar to patients cared for by primary care physicians. This study implies that, absent an enforced clinical practice guideline, hospitalist care of patients with CAP is associated with decreased resource utilization and better outcome.
Finally, in a case-control study, Eron and Passos examined the performance of hospitalists versus infectious disease consultants in the care of hospitalized patients with CAP, cellulitis, or pyelonephritis (14). One hundred eleven patients cared for by infectious disease consultants were compared with 112 historical controls cared for by hospitalists. Patients receiving care from infectious disease specialists had higher patient satisfaction, shorter length of stay, no readmissions, and more rapid return to activities of daily living. The benefits of specialty care were attributable to more frequent use of early outpatient parenteral antibiotic therapy (OPAT) in patients with cellulitis and more rapid switching from parenteral to oral therapy in patients with pyelonephritis and CAP by infectious disease specialists compared with hospitalists. This study has several implications. First, selected inpatients may benefit from early infectious disease consultation. And second, hospitalists may be able to learn from their subspecialty colleagues about the safety and efficacy of early switch therapy and OPAT in selected patient populations.
These limited data suggest that patients with selected infectious diseases may benefit from care provided by hospitalists and infectious disease specialists and that such care is associated with better outcomes and decreased resource utilization. No studies have examined what we believe to be the true potential for improved patient care through the partnership of these 2 disciplines working in collaboration. In the absence of data, we offer several suggestions for areas of fruitful collaboration and further study. First, with the increasing incidence of drug-resistant pathogens and the increasing severity of illness of hospitalized patients with infectious diseases, hospitalists and infectious disease specialists can work together to ensure optimal use of empiric and pathogen-specific antimicrobial therapy and the development and implementation of evidence-based practice guidelines. Second, early infectious disease consultation should be strongly considered in critically ill patients, in those with suspected or confirmed drug-resistant pathogens, and in those with unusual or complicated infectious disease problems. Third, hospitalists, in collaboration with infectious disease specialists, can and should help to improve basic infection control practices, such as hand hygiene and the appropriate use of indwelling devices such as Foley catheters and vascular access devices, which predispose to nosocomial infection. Fourth, hospitalists can facilitate the appropriate immunization of at-risk hospitalized patients against influenza and S. pneumoniae. Finally, hospitalists can partner with their infectious disease colleagues to optimize the use of OPAT and early switch therapy in patients with selected infectious diseases so as to maximize outcome while at the same time reducing hospital length of stay and resource utilization.
In a demonstration project, the Center for Medicare and Medicaid Services has now linked quality measures to reimbursement in several areas of infectious diseases. These include timeliness of antibiotic administration in patients with CAP, blood culture collection prior to antibiotic therapy in patients with CAP, and screening and administering influenza and pneumococcal immunizations to at-risk patients. This trend of linking reimbursement to performance in infectious disease management and prevention is likely to continue.
There are therefore many reasons to encourage partnership and collaboration between these disciplines. These include better quality of care, improved resource utilization, and, hopefully, better reimbursement for hospitals. Through leadership, teamwork, and a multidisciplinary approach, hospitalists and infectious disease physicians should together drive change to realize these goals.
- Pieris JSM, Lai ST, Poon LLM, et al. Coronavirus as a cause of severe acute respiratory syndrome. Lancet. 2003;361:1319-25.
- Reed KD, Melski JW, Graham MB, et al. The detection of monkeypox in humans in the western hemisphere. N Engl J Med. 2004;350:342-50.
- Dhar AD, Werchniak AE, Li Y, et al. Tanapox infection in a college student. N Engl J Med. 2004;350;361-6.
- Paddock CD, Sumner JW, Comer JA, et al. Rickettsia parkeri: a newly recognized cause of spotted fever rickettsiosis in the United States. Clin Infect Dis. 2004;38: 805-11.
- Fridkin SK., Hageman JC, Morrison M, et al. Methicillin resistant Staphylococcus aureus disease in three communities. N Engl J Med. 2005;352:1436-44.
- Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med. 2005;352:1445-53.
- Cosgrove SE, Carroll KC, Perl TM. Staphylococcus aureus with reduced susceptibility to vancomycin. Clin Infect Dis. 2004;39:539-45.
- Whitener CJ, Park SY, Browne FA, et al. Vancomycin resistant Staphylococcus aureus in the absence of vancomycin exposure. Clin Infect Dis. 2004;38:1049-55.
- Whitney CG, Farley MM, Hadler J, et al. Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States. N Engl J Med. 2000;343: 1917-24.
- Davidson R, Cavalcanti R, Brunton JL, et al. Resistance to levofloxacin and failure of treatment of pneumococcal pneumonia. N Engl J Med. 2002;346:747-50.
- Lukehart SA, Godornes C, Molini BJ, et al. Macrolide resistance in Treponema pallidum in the United States and Ireland. N Engl J Med. 2004;351:154-8.
- Reddy JC, Katz PP, Goldman L, Wachter RM. A pneumonia practice guideline and a hospitalist-based reorganization lead to equivalent efficiency gains. Am J Manag Care. 2001;7:1142-8.
- Rifkin WD, Connor D, Silver A, Eichorn A. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77:1053-8.
- Eron LJ, Passos S: Early discharge of infected patients through appropriate antibiotic use. Arch Intern Med. 2001;161:61-5.