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.”