“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 transients. 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
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.
—Robert Orenstein, DO, associate professor of medicinein infectious diseases, Mayo Clinic, Phoenix
As for methicillin-resistant. 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 multi-drug-resistant organisms, he says.