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.