This ID focused pre-course was a jam-packed, practical, and high-yield review of relevant ID topics encountered by practicing hospitalists. Here are some of the key takeaways:
HIV and the Hospitalist in 2013
John Flaherty, MD, prof. of medicine at Northwestern University Feinberg School of Medicine
• Lower the threshold for HIV testing; don’t limit to “high-risk” behaviors, 20% of those living with HIV/AID are unaware—so TEST!
• Recognize clinical clues to HIV infection: acute mono-like syndrome, unexplained chronic illness, comm.-acquired pneumonia.
Thomas Fraser, MD, FACP, FSHEA, vice chairman, Dept. of Infectious Disease, Medical Director for Infection Prevention, Cleveland Clinic
• Risk Factors for CDI: disease severity (sicker patients=higher risk), antibiotics, PPI use, NG tubes and tube feeds, stool softeners and enemas, GI surgery, increasing age.
• Treatment: stop abx if possible, no antiperistaltics, metronidazole 500mg po tid x 10d- 1st line, alt. vancomycin 125-150mg po qid x 10d, vancomycin preferred rx for seriously ill (wbc>20k, ARF, abd.distention, hemodynamic instability).
• Do not treat asymptomatic patient with stool sample + for C. diff.
Emerging Antimicrobial Resistance Issues
COL Glenn Wortmann, MD Chief of integrated Infectious Diseases Services Walter Reed army Medical Center and Bethesda Naval National Naval Center, Program Director of National Capital Consortium Infectious Diseases Fellowship Program, Assoc. Prof. of Medicine Uniformed Services University of the Health Sciences
• Global trends in rising antimicrobial resistance suggest that the antibiotic era may be ending.
• Emphasis shifting from infection treatment to prevention.
• Maximize hand washing: Wash in, wash out and lead by example.
• Consider chlorhexidine washes in high-risk patients as well as environmental decontamination devices.
• Judicious Use of Antimicrobial Agents: use narrow spectrum agents for shortest duration of therapy feasible, formulary restriction, mandatory ID or pharmacy consultation.
How to be a Leader in Antimicrobial Stewardship in Your Hospital
Arjun Srinivasan, MD FSHEA Assoc. Dir. for Healthcare Associated Infection Prevention Programs in the Div. of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC)
• Hospitalists have the greatest influence over how abx are used in hospitals.
• Hospitalists have the background, experience and strong interest in QI work to affect change; know that up to 50% of all antibiotic use is inappropriate.
• Hospitalists can help tackle issues of abx misuse with signouts, handoffs, and care transitions.
ID Emergencies: Diagnoses you can’t afford to miss
James Pile, MD FACP SFHM practicing hospitalist and ID specialist at Cleveland Clinic
• Acute Bacterial Meningitis: LP and Brain Imaging, subset of low-risk patients appears not to require imaging prior to LP, even pts with mild mass effects can probably be safely tapped, herniation may occur even with normal CT-if clinical evidence suggests increasing icp, consider deferring lp or using small gauge needle
• Rx: all adults-cover pneumococcus and meningococcus, empiric coverage of resistant S. pneumoniae is standard of care; cover for listeria for age >50, immunocompromised, alcoholic, pregnant, diabetic; recent head trauma or neurosurgery cover S. aureus and GNB (including pseudomonas).
• Steroids are recommended for suspected BM give dexamethasone with or before antibiotics.
• Spinal Epidural Abscess: It’s easy to miss!
• Necrotizing Fasciitis/Necrotizing Soft Tissue Infections (NSTI): Pain out of proportion to physical findings, systemic findings (delirium, fever, diaphoresis, tachycardia) out of proportion to physical findings; consider Dx to make Dx, easy to miss or delay diagnosis→worsening outcomes. Have low threshold for surgical consultation and/or CT in patients with what appears to be severe cellulitis; include clindamycin (with other abx) for empiric coverage
ID Pearls Every Hospitalist Should Know
John Flaherty, MD
• Re: Perioperative Abx, “Better late than never” does NOT apply. Ensure appropriate timing of peri-op abx.
• Fever ≠ Infection, No Fever ≠ No Infection.
• Sepsis and Hypotension: start broad-spectrum abx NOW.
• Persistent pna despite empiric rx and neg cx, think TB and blastomycoses.
• Fatigue, low-grade fever, and anemia- r/o infective endocarditis.
• Single+blood cx is not always a contaminant; is IS a source of prolonged hospitalization and further testing, so choose wisely when ordering blood cx.
Implementing Socio-Adaptive Change: The role of leaders, followers and bundles in preventing infection
Sanjay Saint, MD MPH Prof. of Int. Medicine University of Michigan, Dir. of the VA/Univeristy of Michigan Patient Safety Enhancement Program, Assoc. Chief of Medicine Ann Arbor VAMC
• Successful implementation of change requires recognition of both the technical and socio-adaptive barriers.
• The key to good leadership is good followership—very little written on subject of followership.
Infective Endocarditis and Intravascular Device Infections
Thomas Fraser, MD FACP FSHEA
• Management Highlights: If patient is sick, pull the line out. If patient has a bad bug, pull the line out. Most people with lines are health care experienced—start broad-spectrum abx and tailor rx once cx available. If you do not pull the line, follow very closely, have low threshold to call ID consult, S. aureus is in a class all its own.
• When can line be replaced? Timing depends on clinical need ultimately, clinically well with resolving syndrome, receiving effective rx, blood cx neg for 72 hrs; maybe longer for Candida species.
• Who should get a TEE for HCA S. aureus bacteremia? Patients with prolonged bacteremia; >4 days; presence of an intracardiac device (valve, icd, ppm); metastatic complication; vertebral or other osteomyelitis, etc. TH
Dr. Lindsey is a COO at Strategist Synergy Surgicalists, lead consultant at Asynd Consulting, and a Team Hospitalist member.