Monday, March 11, 2013

The Value of a Formal Infectious Diseases Consult

Those who work closely with me know that I prefer to convert curbside consultations to formal consultations. Why? Well, since I am not a fee-for-service private doctor, finances are not a consideration. Rather, I have always felt that curbside or telephone consults are performed with inadequate clinical information to result in meaningful diagnostic and management recommendations.

Here is a paper recently published in Clinical Infectious Diseases that highlights the clinical value of a formal infectious diseases consultation compared to a telephone consultation for the management of S.aureus bacteremia.

The investigators retrospectively studied 342 S.aureus bacteremia (SAB) episodes with 90-day follow-up. Patients were grouped according to bedside, telephone, or no infectious diseases service (IDS) consultation within the first week. 

Seventy-two percent of patients received bedside, 18% telephone, and 10% no IDS consultation. Patients with bedside consultation were less often treated in an intensive care unit during the first 3 days compared to those with telephone consultation (odds ratio [OR], 0.53; 95% confidence interval [CI], .29-.97; P = .037; 21% vs 34%), with no other initial differences between these groups. Patients with bedside consultation more often had deep infection foci localized as compared to patients with telephone consultation (OR, 3.11; 95% CI, 1.74-5.57; P < .0001; 78% vs 53%). Patients with bedside consultation had lower mortality than patients with telephone consultation at 7 days (OR, 0.09; 95% CI, .02-.49; P = .001; 1% vs 8%), at 28 days (OR, 0.27; 95% CI, .11-.65; P = .002; 5% vs 16%) and at 90 days (OR, 0.25; 95% CI, .13-.51; P < .0001; 9% vs 29%). Considering all prognostic markers, 90-day mortality for telephone-consultation patients was higher (OR, 2.31; CI, 95% 1.22-4.38; P = .01) as compared to bedside consultation.

The bottom line, in cases of SAB infectious diseases consultation was associated with decreased mortality. Patients with a formal infectious diseases consult likely underwent more thorough assessment, including additional diagnostic testing and more appropriate duration of antibiotic treatment. 

If available, a former infectious diseases consult is better than an over the telephone or curbside consult.

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