Thomas R. Collins

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

Click here to listen to Dr. Eichhorn

Click here to listen to Dr. Eichhorn

Click here to listen to Dr. Eichhorn

Click here to listen to Dr. Scheurer

Click here to listen to Dr. Scheurer

Click here to listen to Dr. Scheurer

The Hospitalist surveyed half a dozen infectious disease (ID) experts—some of whom also have experience as hospitalists—what they would tell a roomful of hospitalists who were curious about ID. Based on those discussions, we offer 10 tips that should help hospitalists treat their patients more effectively.

Hospitalists routinely care for patients with infections, or symptoms of infections, or suspected infections that might not even be infections at all. Many times, hospitalists have more than one treatment option. So which is the best to use? Is there a better option than the therapy that first comes to mind? What about that new antibiotic out there—is it really worth it?

All the while, hospitalists who want to practice conscientious medicine have to be careful they don’t overuse broad-spectrum antibiotics so that bugs’ resistance to the drugs is not speeded up unnecessarily.

In short, infectious diseases can be dicey terrain.

1. Prepare for the reality that the availability of new drugs is shrinking because of antibiotic resistance.

That grim fact might be cause for hospitalists to seek help from ID specialists at their hospitals, says John Bartlett, MD, professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore and founding director of the Center for Civilian Biodefense Strategies. The FDA has approved just two new drugs for major infections in the last five years, he says.

“The FDA faucet is really dry,” says Dr. Bartlett, a world-renowned speaker on ID topics and a frequent speaker at SHM annual meetings. “There are no new antibiotics to speak of, no new antibiotics for resistant bacteria. And there’s not likely to be any for several years. So [hospitalists] are going to find themselves painted in a corner, and they’ll probably have to ask for help.”

Leland Allen, MD, an infectious-disease specialist at Shelby Baptist Medical Center near Birmingham, Ala., who worked as a hospitalist for nine years, says hospitalists should not hesitate to seek assistance. “It’s never a burden to do a consult,” he says. “The reality is that it’s a lot less work if you consult early rather than waiting until the patient is sick.”

Dr. Bartlett says hospitalists should brush up on the use of colistin, a drug developed in 1959 that has been little used and requires careful dosing to avoid toxicity. “We’re finding more and more patients that that’s the only thing we’ve got for them,” he says.

2. Familiarize yourself with new technologyfor identifying bugs.

“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,” says Robert Orenstein, DO, associate professor of medicine in infectious diseases at the Mayo Clinic in Phoenix. “This allows you potentially to identify some of these microorganisms almost immediately—if they’re in the database, which is the key.”

Dr. Bartlett says it’s important for hospitalists to pay attention to the “dramatic changes” in the technology, including the emergence of the ppolymerase chain reaction (PCR) test.

“They have to be aware that there are methods that are very sophisticated and very sensitive and specific,” he says, adding that hospitalists have to keep up with what the methods can measure and what their limitations are.

 

“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

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.

 

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."

 

Tom Collins is a freelance writer in South Florida

References

1. Kim SH, Kim KH, Kim HB, et al. Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus aureus bacteremia. Antimicrob Agents Chemother. 2008;52(1):192-197.
2. González C, Rubio M, Romero-Vivas J, González M, Picazo JJ.. Bacteremic pneumonia due to Staphylococcus aureus: A comparison of disease caused by methicillin-resistant and methicillin-susceptible organisms. Clin Infect Dis. 1999;29(5):1171-1177.
3. Stryjewski ME, Szczech LA, Benjamin DK Jr., et al. Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis. 2007;44(2):190-196.

The Hospitalist surveyed half a dozen infectious disease (ID) experts—some of whom also have experience as hospitalists—what they would tell a roomful of hospitalists who were curious about ID. Based on those discussions, we offer 10 tips that should help hospitalists treat their patients more effectively.

Hospitalists routinely care for patients with infections, or symptoms of infections, or suspected infections that might not even be infections at all. Many times, hospitalists have more than one treatment option. So which is the best to use? Is there a better option than the therapy that first comes to mind? What about that new antibiotic out there—is it really worth it?

All the while, hospitalists who want to practice conscientious medicine have to be careful they don’t overuse broad-spectrum antibiotics so that bugs’ resistance to the drugs is not speeded up unnecessarily.

In short, infectious diseases can be dicey terrain.

1. Prepare for the reality that the availability of new drugs is shrinking because of antibiotic resistance.

That grim fact might be cause for hospitalists to seek help from ID specialists at their hospitals, says John Bartlett, MD, professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore and founding director of the Center for Civilian Biodefense Strategies. The FDA has approved just two new drugs for major infections in the last five years, he says.

“The FDA faucet is really dry,” says Dr. Bartlett, a world-renowned speaker on ID topics and a frequent speaker at SHM annual meetings. “There are no new antibiotics to speak of, no new antibiotics for resistant bacteria. And there’s not likely to be any for several years. So [hospitalists] are going to find themselves painted in a corner, and they’ll probably have to ask for help.”

Leland Allen, MD, an infectious-disease specialist at Shelby Baptist Medical Center near Birmingham, Ala., who worked as a hospitalist for nine years, says hospitalists should not hesitate to seek assistance. “It’s never a burden to do a consult,” he says. “The reality is that it’s a lot less work if you consult early rather than waiting until the patient is sick.”

Dr. Bartlett says hospitalists should brush up on the use of colistin, a drug developed in 1959 that has been little used and requires careful dosing to avoid toxicity. “We’re finding more and more patients that that’s the only thing we’ve got for them,” he says.

2. Familiarize yourself with new technologyfor identifying bugs.

“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,” says Robert Orenstein, DO, associate professor of medicine in infectious diseases at the Mayo Clinic in Phoenix. “This allows you potentially to identify some of these microorganisms almost immediately—if they’re in the database, which is the key.”

Dr. Bartlett says it’s important for hospitalists to pay attention to the “dramatic changes” in the technology, including the emergence of the ppolymerase chain reaction (PCR) test.

“They have to be aware that there are methods that are very sophisticated and very sensitive and specific,” he says, adding that hospitalists have to keep up with what the methods can measure and what their limitations are.

 

“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

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.

 

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."

 

Tom Collins is a freelance writer in South Florida

References

1. Kim SH, Kim KH, Kim HB, et al. Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus aureus bacteremia. Antimicrob Agents Chemother. 2008;52(1):192-197.
2. González C, Rubio M, Romero-Vivas J, González M, Picazo JJ.. Bacteremic pneumonia due to Staphylococcus aureus: A comparison of disease caused by methicillin-resistant and methicillin-susceptible organisms. Clin Infect Dis. 1999;29(5):1171-1177.
3. Stryjewski ME, Szczech LA, Benjamin DK Jr., et al. Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis. 2007;44(2):190-196.

The Hospitalist surveyed half a dozen infectious disease (ID) experts—some of whom also have experience as hospitalists—what they would tell a roomful of hospitalists who were curious about ID. Based on those discussions, we offer 10 tips that should help hospitalists treat their patients more effectively.

Hospitalists routinely care for patients with infections, or symptoms of infections, or suspected infections that might not even be infections at all. Many times, hospitalists have more than one treatment option. So which is the best to use? Is there a better option than the therapy that first comes to mind? What about that new antibiotic out there—is it really worth it?

All the while, hospitalists who want to practice conscientious medicine have to be careful they don’t overuse broad-spectrum antibiotics so that bugs’ resistance to the drugs is not speeded up unnecessarily.

In short, infectious diseases can be dicey terrain.

1. Prepare for the reality that the availability of new drugs is shrinking because of antibiotic resistance.

That grim fact might be cause for hospitalists to seek help from ID specialists at their hospitals, says John Bartlett, MD, professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore and founding director of the Center for Civilian Biodefense Strategies. The FDA has approved just two new drugs for major infections in the last five years, he says.

“The FDA faucet is really dry,” says Dr. Bartlett, a world-renowned speaker on ID topics and a frequent speaker at SHM annual meetings. “There are no new antibiotics to speak of, no new antibiotics for resistant bacteria. And there’s not likely to be any for several years. So [hospitalists] are going to find themselves painted in a corner, and they’ll probably have to ask for help.”

Leland Allen, MD, an infectious-disease specialist at Shelby Baptist Medical Center near Birmingham, Ala., who worked as a hospitalist for nine years, says hospitalists should not hesitate to seek assistance. “It’s never a burden to do a consult,” he says. “The reality is that it’s a lot less work if you consult early rather than waiting until the patient is sick.”

Dr. Bartlett says hospitalists should brush up on the use of colistin, a drug developed in 1959 that has been little used and requires careful dosing to avoid toxicity. “We’re finding more and more patients that that’s the only thing we’ve got for them,” he says.

2. Familiarize yourself with new technologyfor identifying bugs.

“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,” says Robert Orenstein, DO, associate professor of medicine in infectious diseases at the Mayo Clinic in Phoenix. “This allows you potentially to identify some of these microorganisms almost immediately—if they’re in the database, which is the key.”

Dr. Bartlett says it’s important for hospitalists to pay attention to the “dramatic changes” in the technology, including the emergence of the ppolymerase chain reaction (PCR) test.

“They have to be aware that there are methods that are very sophisticated and very sensitive and specific,” he says, adding that hospitalists have to keep up with what the methods can measure and what their limitations are.

 

“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

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.

 

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."

 

Tom Collins is a freelance writer in South Florida

References

1. Kim SH, Kim KH, Kim HB, et al. Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus aureus bacteremia. Antimicrob Agents Chemother. 2008;52(1):192-197.
2. González C, Rubio M, Romero-Vivas J, González M, Picazo JJ.. Bacteremic pneumonia due to Staphylococcus aureus: A comparison of disease caused by methicillin-resistant and methicillin-susceptible organisms. Clin Infect Dis. 1999;29(5):1171-1177.
3. Stryjewski ME, Szczech LA, Benjamin DK Jr., et al. Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis. 2007;44(2):190-196.

There has always been a journalist dwelling in Danielle Scheurer, MD, MSCR, SFHM. As an undergrad at Emory University, she saw TV reporting in her future.

“I was on the Katie Couric kick for a decade,” she says.

Her course eventually shifted—dramatically. But since she became a hospitalist, Dr. Scheurer, now the chief quality officer at the Medical University of South Carolina (MUSC) in Charleston, has stayed involved with a long slate of editorial projects.

Her latest: She is the new physician editor of The Hospitalist. With the appointment, the magazine gains a high-energy physician with a broad spectrum of knowledge. Colleagues say she has a knack for seeing the big picture and taking a bolus of information and conveying its relevance to hospitalists and other medical professionals.

Dr. Scheurer says that one of her aims will be to make the publication’s website—www.the-hospitalist.org—more interactive, allowing for more direct participation from readers, such as with polls and forums on topics covered.

“A lot of us in the hospital sort of struggle with the exact same things,” she says. “I think there’s some value in connecting, even if it’s in just short little snippets.”

She also would like to increase the website’s use of audio files so that doctors have more options in how they get their information.

But above all, she says, she wants to keep The Hospitalist “one of the most practical publications available to hospitalists,” a publication that is specifically tailored to deliver useful messages.

“I feel like it’s a very high-yield publication for really busy hospitalists,” she says.

Career Shuffle = Diverse Experience

Dr. Scheurer brings experience from a variety of settings, such as the small community hospital Trident Medical Center in Charleston to the large, urban medical centers that are Brigham and Women’s Hospital in Boston and MUSC.

She said some of her career moves came with some apprehension, including those that came about when her husband got a position that required her to move, too. But she says she has benefited from those experiences. Trident “gave me a window into hospital medicine that I never otherwise would have had,” she notes.

She never anticipated moving to Boston, and she admits it felt outside of her “comfort zone.” But in 2005, she found herself at Brigham. She had just earned a master’s degree in clinical research and thought she’d end up being a researcher. In Boston, she got a glimpse of what it meant to be a “hard-core, NIH-funded researcher” and decided it wasn’t for her.

While there, she took training courses in leadership and quality improvement. And QI stuck.

In 2010, she returned to MUSC and now leads QI for the whole hospital, a medium-size setting that she says is just right for promoting change.

“This is definitely my sweet spot,” she says. “If you’re going to change people’s minds, it’s a lot easer to change 200 people’s minds than 450 people’s minds.”

Chris Roy, MD, medical director of the hospitalist service at Brigham, says Dr. Scheurer was “one of the most-hard working people that I knew” and a strong leader with an “uncanny, almost photographic memory of all the hospital medicine literature.”

“Even though she was very forceful as a leader, she never irritated anyone,” he adds. “She was very skillful in managing people.”

 

Chris Rees, the director of quality and patient safety at MUSC, says Dr. Scheurer is adept at taking issues that evolve from the hospital and collaborating on them with other university departments. She is good at putting herself in other groups’ shoes and delivering messages succinctly, he says.

“She’s definitely not seen as just one of those white coats,” Rees says.

Highly Recommended

On top of her QI projects, Dr. Scheurer is involved as an advisor, contributor, or reviewer at 11 other publications or online venues. The Hospitalist will make it an even dozen.

“She’s just a dynamo,” Rees says. “She walks around with her MacAir book and she’s constantly writing stuff on it and sending out emails.”

Patrick Cawley, MD, MBA, MHM, the chief medical officer at MUSC who hired Dr. Scheurer when she first worked there in 2003, has seen her move from small projects to systemwide efforts.

“She did a great job and is very collaborative, very knowledgeable, [and] brings an evidence-based approach to problems,” says Dr. Cawley, a past president of SHM and recent inductee as a Master in Hospital Medicine (MHM).

She is quick to notice trends and patterns, he points out. “She’s very knowledgeable about what’s going on in the hospitalist arena,” he says, adding he anticipates she’ll be interested in “data-driven” coverage, along with QI topics.

Dr. Scheurer’s interest in disseminating information shouldn’t be a surprise—it’s a fundamental part of QI and instrumental in systemwide change. She finds it “appealing to work on a project and know that it’s going to affect the next 20,000 patients.”

“There’s no one single person that can ensure that the patient gets all of their needs met,” she says. “There has to be a system approach.”

At The Hospitalist, she will try to keep pace with all the change that hospitals are constantly trying to navigate.

“I don’t think there will ever be a deficiency of content to cover,” she says. “Something’s always brand-new.”

Tom Collins is a freelance writer in Florida.

There has always been a journalist dwelling in Danielle Scheurer, MD, MSCR, SFHM. As an undergrad at Emory University, she saw TV reporting in her future.

“I was on the Katie Couric kick for a decade,” she says.

Her course eventually shifted—dramatically. But since she became a hospitalist, Dr. Scheurer, now the chief quality officer at the Medical University of South Carolina (MUSC) in Charleston, has stayed involved with a long slate of editorial projects.

Her latest: She is the new physician editor of The Hospitalist. With the appointment, the magazine gains a high-energy physician with a broad spectrum of knowledge. Colleagues say she has a knack for seeing the big picture and taking a bolus of information and conveying its relevance to hospitalists and other medical professionals.

Dr. Scheurer says that one of her aims will be to make the publication’s website—www.the-hospitalist.org—more interactive, allowing for more direct participation from readers, such as with polls and forums on topics covered.

“A lot of us in the hospital sort of struggle with the exact same things,” she says. “I think there’s some value in connecting, even if it’s in just short little snippets.”

She also would like to increase the website’s use of audio files so that doctors have more options in how they get their information.

But above all, she says, she wants to keep The Hospitalist “one of the most practical publications available to hospitalists,” a publication that is specifically tailored to deliver useful messages.

“I feel like it’s a very high-yield publication for really busy hospitalists,” she says.

Career Shuffle = Diverse Experience

Dr. Scheurer brings experience from a variety of settings, such as the small community hospital Trident Medical Center in Charleston to the large, urban medical centers that are Brigham and Women’s Hospital in Boston and MUSC.

She said some of her career moves came with some apprehension, including those that came about when her husband got a position that required her to move, too. But she says she has benefited from those experiences. Trident “gave me a window into hospital medicine that I never otherwise would have had,” she notes.

She never anticipated moving to Boston, and she admits it felt outside of her “comfort zone.” But in 2005, she found herself at Brigham. She had just earned a master’s degree in clinical research and thought she’d end up being a researcher. In Boston, she got a glimpse of what it meant to be a “hard-core, NIH-funded researcher” and decided it wasn’t for her.

While there, she took training courses in leadership and quality improvement. And QI stuck.

In 2010, she returned to MUSC and now leads QI for the whole hospital, a medium-size setting that she says is just right for promoting change.

“This is definitely my sweet spot,” she says. “If you’re going to change people’s minds, it’s a lot easer to change 200 people’s minds than 450 people’s minds.”

Chris Roy, MD, medical director of the hospitalist service at Brigham, says Dr. Scheurer was “one of the most-hard working people that I knew” and a strong leader with an “uncanny, almost photographic memory of all the hospital medicine literature.”

“Even though she was very forceful as a leader, she never irritated anyone,” he adds. “She was very skillful in managing people.”

 

Chris Rees, the director of quality and patient safety at MUSC, says Dr. Scheurer is adept at taking issues that evolve from the hospital and collaborating on them with other university departments. She is good at putting herself in other groups’ shoes and delivering messages succinctly, he says.

“She’s definitely not seen as just one of those white coats,” Rees says.

Highly Recommended

On top of her QI projects, Dr. Scheurer is involved as an advisor, contributor, or reviewer at 11 other publications or online venues. The Hospitalist will make it an even dozen.

“She’s just a dynamo,” Rees says. “She walks around with her MacAir book and she’s constantly writing stuff on it and sending out emails.”

Patrick Cawley, MD, MBA, MHM, the chief medical officer at MUSC who hired Dr. Scheurer when she first worked there in 2003, has seen her move from small projects to systemwide efforts.

“She did a great job and is very collaborative, very knowledgeable, [and] brings an evidence-based approach to problems,” says Dr. Cawley, a past president of SHM and recent inductee as a Master in Hospital Medicine (MHM).

She is quick to notice trends and patterns, he points out. “She’s very knowledgeable about what’s going on in the hospitalist arena,” he says, adding he anticipates she’ll be interested in “data-driven” coverage, along with QI topics.

Dr. Scheurer’s interest in disseminating information shouldn’t be a surprise—it’s a fundamental part of QI and instrumental in systemwide change. She finds it “appealing to work on a project and know that it’s going to affect the next 20,000 patients.”

“There’s no one single person that can ensure that the patient gets all of their needs met,” she says. “There has to be a system approach.”

At The Hospitalist, she will try to keep pace with all the change that hospitals are constantly trying to navigate.

“I don’t think there will ever be a deficiency of content to cover,” she says. “Something’s always brand-new.”

Tom Collins is a freelance writer in Florida.

There has always been a journalist dwelling in Danielle Scheurer, MD, MSCR, SFHM. As an undergrad at Emory University, she saw TV reporting in her future.

“I was on the Katie Couric kick for a decade,” she says.

Her course eventually shifted—dramatically. But since she became a hospitalist, Dr. Scheurer, now the chief quality officer at the Medical University of South Carolina (MUSC) in Charleston, has stayed involved with a long slate of editorial projects.

Her latest: She is the new physician editor of The Hospitalist. With the appointment, the magazine gains a high-energy physician with a broad spectrum of knowledge. Colleagues say she has a knack for seeing the big picture and taking a bolus of information and conveying its relevance to hospitalists and other medical professionals.

Dr. Scheurer says that one of her aims will be to make the publication’s website—www.the-hospitalist.org—more interactive, allowing for more direct participation from readers, such as with polls and forums on topics covered.

“A lot of us in the hospital sort of struggle with the exact same things,” she says. “I think there’s some value in connecting, even if it’s in just short little snippets.”

She also would like to increase the website’s use of audio files so that doctors have more options in how they get their information.

But above all, she says, she wants to keep The Hospitalist “one of the most practical publications available to hospitalists,” a publication that is specifically tailored to deliver useful messages.

“I feel like it’s a very high-yield publication for really busy hospitalists,” she says.

Career Shuffle = Diverse Experience

Dr. Scheurer brings experience from a variety of settings, such as the small community hospital Trident Medical Center in Charleston to the large, urban medical centers that are Brigham and Women’s Hospital in Boston and MUSC.

She said some of her career moves came with some apprehension, including those that came about when her husband got a position that required her to move, too. But she says she has benefited from those experiences. Trident “gave me a window into hospital medicine that I never otherwise would have had,” she notes.

She never anticipated moving to Boston, and she admits it felt outside of her “comfort zone.” But in 2005, she found herself at Brigham. She had just earned a master’s degree in clinical research and thought she’d end up being a researcher. In Boston, she got a glimpse of what it meant to be a “hard-core, NIH-funded researcher” and decided it wasn’t for her.

While there, she took training courses in leadership and quality improvement. And QI stuck.

In 2010, she returned to MUSC and now leads QI for the whole hospital, a medium-size setting that she says is just right for promoting change.

“This is definitely my sweet spot,” she says. “If you’re going to change people’s minds, it’s a lot easer to change 200 people’s minds than 450 people’s minds.”

Chris Roy, MD, medical director of the hospitalist service at Brigham, says Dr. Scheurer was “one of the most-hard working people that I knew” and a strong leader with an “uncanny, almost photographic memory of all the hospital medicine literature.”

“Even though she was very forceful as a leader, she never irritated anyone,” he adds. “She was very skillful in managing people.”

 

Chris Rees, the director of quality and patient safety at MUSC, says Dr. Scheurer is adept at taking issues that evolve from the hospital and collaborating on them with other university departments. She is good at putting herself in other groups’ shoes and delivering messages succinctly, he says.

“She’s definitely not seen as just one of those white coats,” Rees says.

Highly Recommended

On top of her QI projects, Dr. Scheurer is involved as an advisor, contributor, or reviewer at 11 other publications or online venues. The Hospitalist will make it an even dozen.

“She’s just a dynamo,” Rees says. “She walks around with her MacAir book and she’s constantly writing stuff on it and sending out emails.”

Patrick Cawley, MD, MBA, MHM, the chief medical officer at MUSC who hired Dr. Scheurer when she first worked there in 2003, has seen her move from small projects to systemwide efforts.

“She did a great job and is very collaborative, very knowledgeable, [and] brings an evidence-based approach to problems,” says Dr. Cawley, a past president of SHM and recent inductee as a Master in Hospital Medicine (MHM).

She is quick to notice trends and patterns, he points out. “She’s very knowledgeable about what’s going on in the hospitalist arena,” he says, adding he anticipates she’ll be interested in “data-driven” coverage, along with QI topics.

Dr. Scheurer’s interest in disseminating information shouldn’t be a surprise—it’s a fundamental part of QI and instrumental in systemwide change. She finds it “appealing to work on a project and know that it’s going to affect the next 20,000 patients.”

“There’s no one single person that can ensure that the patient gets all of their needs met,” she says. “There has to be a system approach.”

At The Hospitalist, she will try to keep pace with all the change that hospitals are constantly trying to navigate.

“I don’t think there will ever be a deficiency of content to cover,” she says. “Something’s always brand-new.”

Tom Collins is a freelance writer in Florida.

Hospitalists routinely have to handle infection cases, but how well trained are they to do so, and how well prepared are the hospitals they work in to support them on difficult cases?

It depends on training and the institution, but both areas have room for improvement, says a physician who has had feet on both sides of the fence.

Leland Allen, MD, says there is no easy answer on whether hospitalists have enough baseline training.

“What I see locally in Birmingham is that there is a wide variation in the training,” he says. “The hospitalists that I see that are family-practice-trained, just as the nature of the family practice training [goes], have a whole lot of outpatient experience. And so these people don’t have nearly the inpatient experience in their training that people trained in internal medicine do.”

Some hospitalists, Dr. Allen says, are as proficient in dealing with inpatient ID cases as he is. Others are clueless, he says. “It really just depends on the training. It would be nice if there was some standardization of training, rather than just kind of catch-as-catch-can.”

As for ID resources available at hospitals, Dr. Allen says, “there is potential in any hospital to have an excellent backbone program of infection control.” But that depends on the availability of ID experts and the willingness of hospital administration to invest in the program.

“A well-developed, well-maintained infection-control program, with a good infection-control nurse, can really help a hospitalist to understand the types of infections that they’re up against in that particular institution,” Dr. Allen explains. “It really pays off down the road for the hospital with reduced infection rates, and also physicians who are practicing in the hospital, in terms of making their life a little bit easier.”

And with changes in Medicare reimbursement for hospital-acquired infections, he says, “it really behooves a hospital to spend some money up front.”

Hospitalists routinely have to handle infection cases, but how well trained are they to do so, and how well prepared are the hospitals they work in to support them on difficult cases?

It depends on training and the institution, but both areas have room for improvement, says a physician who has had feet on both sides of the fence.

Leland Allen, MD, says there is no easy answer on whether hospitalists have enough baseline training.

“What I see locally in Birmingham is that there is a wide variation in the training,” he says. “The hospitalists that I see that are family-practice-trained, just as the nature of the family practice training [goes], have a whole lot of outpatient experience. And so these people don’t have nearly the inpatient experience in their training that people trained in internal medicine do.”

Some hospitalists, Dr. Allen says, are as proficient in dealing with inpatient ID cases as he is. Others are clueless, he says. “It really just depends on the training. It would be nice if there was some standardization of training, rather than just kind of catch-as-catch-can.”

As for ID resources available at hospitals, Dr. Allen says, “there is potential in any hospital to have an excellent backbone program of infection control.” But that depends on the availability of ID experts and the willingness of hospital administration to invest in the program.

“A well-developed, well-maintained infection-control program, with a good infection-control nurse, can really help a hospitalist to understand the types of infections that they’re up against in that particular institution,” Dr. Allen explains. “It really pays off down the road for the hospital with reduced infection rates, and also physicians who are practicing in the hospital, in terms of making their life a little bit easier.”

And with changes in Medicare reimbursement for hospital-acquired infections, he says, “it really behooves a hospital to spend some money up front.”

Hospitalists routinely have to handle infection cases, but how well trained are they to do so, and how well prepared are the hospitals they work in to support them on difficult cases?

It depends on training and the institution, but both areas have room for improvement, says a physician who has had feet on both sides of the fence.

Leland Allen, MD, says there is no easy answer on whether hospitalists have enough baseline training.

“What I see locally in Birmingham is that there is a wide variation in the training,” he says. “The hospitalists that I see that are family-practice-trained, just as the nature of the family practice training [goes], have a whole lot of outpatient experience. And so these people don’t have nearly the inpatient experience in their training that people trained in internal medicine do.”

Some hospitalists, Dr. Allen says, are as proficient in dealing with inpatient ID cases as he is. Others are clueless, he says. “It really just depends on the training. It would be nice if there was some standardization of training, rather than just kind of catch-as-catch-can.”

As for ID resources available at hospitals, Dr. Allen says, “there is potential in any hospital to have an excellent backbone program of infection control.” But that depends on the availability of ID experts and the willingness of hospital administration to invest in the program.

“A well-developed, well-maintained infection-control program, with a good infection-control nurse, can really help a hospitalist to understand the types of infections that they’re up against in that particular institution,” Dr. Allen explains. “It really pays off down the road for the hospital with reduced infection rates, and also physicians who are practicing in the hospital, in terms of making their life a little bit easier.”

And with changes in Medicare reimbursement for hospital-acquired infections, he says, “it really behooves a hospital to spend some money up front.”

It might seem basic, but ID experts say it’s too important not to repeat it over and over again: Hospitalists have to take care to narrowly tailor patients’ antibiotic treatments.

Starting a patient on broad-spectrum therapies might be necessary, but once the culprit is identified, the therapy should be honed, they say.

“I think frequently people who get started on antibiotics empirically in the emergency room, they’ll come into the hospital and they’ll kind of stay on them because folks are sometimes afraid to stop them,” Dr. Chansolme says. “But don’t be afraid to do that, particularly in this era of multi-drug resistance.”

Dr. Allen says scaling down treatment might not be easy in the middle of a busy day, but that it must be done.

“The path of least resistance is always to do nothing,” he says. “Even sometimes when you’re 100% certain [about the precise bug requiring

treatment], there’s this little voice in the back of your head going, ‘Yeah, but what if?’ It really does take some thought, and [courage], to stop antibiotics when the patient’s getting better on the current therapy.”

Dr. Gupta of the CDC says HM programs are in prime position to influence a hospital’s practices. “It’s important to remember appropriate use of antimicrobials and treatment and prevention of hospital-acquired infections when they are practicing that they’re often influencing physicians and training,” he says.

The experts raise a few red flags and offer tips that, if followed, should help hospitalists improve their antimicrobial stewardship:

Dr. Chansolme cautions that “not all fluoroquinolones are created equal” and are not interchangeable. In particular, he notes, moxifloxacin is not good for pseudomonas and doesn’t cover UTIs.

• Dr. Allen says that metronidazole does not have to be given if you’re already giving Zosyn or a carbapenem—it doesn’t add anything to the treatment.
• Dr. Allen also says it’s important to remember that cellulitis is almost always just a gram-positive infection, and does not require a very broad-spectrum antibiotic, a mistake he often sees.
• Dr. Orenstein says hospitalists should be on the lookout for the procalcitonin test, a laboratory study based on a prohormone that tends to be elevated in the setting of bacterial infections. The test can be used to possibly shorten the length of time a patient is given an antibiotic in certain cases.

“If elevated and you followed it, you could use it as a marker for when you could stop your antibiotics,” Dr. Orenstein said.

He says the test generally has been shown to allow doctors to shorten the course of antibiotics by one or two days, which can save on cost and length of stay.

“People need to be aware of it,” he says, “as I think a lot of places will be using it. It’s not quite ready for prime time.”

It might seem basic, but ID experts say it’s too important not to repeat it over and over again: Hospitalists have to take care to narrowly tailor patients’ antibiotic treatments.

Starting a patient on broad-spectrum therapies might be necessary, but once the culprit is identified, the therapy should be honed, they say.

“I think frequently people who get started on antibiotics empirically in the emergency room, they’ll come into the hospital and they’ll kind of stay on them because folks are sometimes afraid to stop them,” Dr. Chansolme says. “But don’t be afraid to do that, particularly in this era of multi-drug resistance.”

Dr. Allen says scaling down treatment might not be easy in the middle of a busy day, but that it must be done.

“The path of least resistance is always to do nothing,” he says. “Even sometimes when you’re 100% certain [about the precise bug requiring

treatment], there’s this little voice in the back of your head going, ‘Yeah, but what if?’ It really does take some thought, and [courage], to stop antibiotics when the patient’s getting better on the current therapy.”

Dr. Gupta of the CDC says HM programs are in prime position to influence a hospital’s practices. “It’s important to remember appropriate use of antimicrobials and treatment and prevention of hospital-acquired infections when they are practicing that they’re often influencing physicians and training,” he says.

The experts raise a few red flags and offer tips that, if followed, should help hospitalists improve their antimicrobial stewardship:

Dr. Chansolme cautions that “not all fluoroquinolones are created equal” and are not interchangeable. In particular, he notes, moxifloxacin is not good for pseudomonas and doesn’t cover UTIs.

• Dr. Allen says that metronidazole does not have to be given if you’re already giving Zosyn or a carbapenem—it doesn’t add anything to the treatment.
• Dr. Allen also says it’s important to remember that cellulitis is almost always just a gram-positive infection, and does not require a very broad-spectrum antibiotic, a mistake he often sees.
• Dr. Orenstein says hospitalists should be on the lookout for the procalcitonin test, a laboratory study based on a prohormone that tends to be elevated in the setting of bacterial infections. The test can be used to possibly shorten the length of time a patient is given an antibiotic in certain cases.

“If elevated and you followed it, you could use it as a marker for when you could stop your antibiotics,” Dr. Orenstein said.

He says the test generally has been shown to allow doctors to shorten the course of antibiotics by one or two days, which can save on cost and length of stay.

“People need to be aware of it,” he says, “as I think a lot of places will be using it. It’s not quite ready for prime time.”

It might seem basic, but ID experts say it’s too important not to repeat it over and over again: Hospitalists have to take care to narrowly tailor patients’ antibiotic treatments.

Starting a patient on broad-spectrum therapies might be necessary, but once the culprit is identified, the therapy should be honed, they say.

“I think frequently people who get started on antibiotics empirically in the emergency room, they’ll come into the hospital and they’ll kind of stay on them because folks are sometimes afraid to stop them,” Dr. Chansolme says. “But don’t be afraid to do that, particularly in this era of multi-drug resistance.”

Dr. Allen says scaling down treatment might not be easy in the middle of a busy day, but that it must be done.

“The path of least resistance is always to do nothing,” he says. “Even sometimes when you’re 100% certain [about the precise bug requiring

treatment], there’s this little voice in the back of your head going, ‘Yeah, but what if?’ It really does take some thought, and [courage], to stop antibiotics when the patient’s getting better on the current therapy.”

Dr. Gupta of the CDC says HM programs are in prime position to influence a hospital’s practices. “It’s important to remember appropriate use of antimicrobials and treatment and prevention of hospital-acquired infections when they are practicing that they’re often influencing physicians and training,” he says.

The experts raise a few red flags and offer tips that, if followed, should help hospitalists improve their antimicrobial stewardship:

Dr. Chansolme cautions that “not all fluoroquinolones are created equal” and are not interchangeable. In particular, he notes, moxifloxacin is not good for pseudomonas and doesn’t cover UTIs.

• Dr. Allen says that metronidazole does not have to be given if you’re already giving Zosyn or a carbapenem—it doesn’t add anything to the treatment.
• Dr. Allen also says it’s important to remember that cellulitis is almost always just a gram-positive infection, and does not require a very broad-spectrum antibiotic, a mistake he often sees.
• Dr. Orenstein says hospitalists should be on the lookout for the procalcitonin test, a laboratory study based on a prohormone that tends to be elevated in the setting of bacterial infections. The test can be used to possibly shorten the length of time a patient is given an antibiotic in certain cases.

“If elevated and you followed it, you could use it as a marker for when you could stop your antibiotics,” Dr. Orenstein said.

He says the test generally has been shown to allow doctors to shorten the course of antibiotics by one or two days, which can save on cost and length of stay.

“People need to be aware of it,” he says, “as I think a lot of places will be using it. It’s not quite ready for prime time.”

Click here to listen to Dr. Allen

Click here to listen to Dr. Allen

Click here to listen to Dr. Allen

A Centers for Disease Control report on Clostridium difficile infections offers encouragement for hospitalists that prevention is possible, but also offers further evidence that more work is needed to prevent the potentially deadly infections.

The report examines three sets of data on C. diff infections. According to an analysis of the CDC’s Emerging Infections Program, 94% of the more than 10,000 infections identified were related to the receipt of healthcare. Also, 75% of the infections had their onset in patients who were not hospitalized at the time.

An analysis of National Healthcare Safety Network data of present-at-admission and hospital-onset C. diff infections found that 52% of the cases involved patients already infected at admission, although they were largely healthcare-related.

And an analysis of data from three state-administered CDI-prevention projects in Illinois, Massachusetts, and New York found that, cumulatively, C. diff infections were reduced by 20%, showing that prevention efforts can pay off.

The heavy involvement of healthcare settings in infections shows that more should be done, says Clifford McDonald, MD, chief of prevention and response in CDC’s Division of Healthcare Quality and Promotion in Atlanta. He took aim specifically at careful use of antibiotics, as broad-spectrum antibiotics kill off bacteria that can help keep C. diff at bay.

“Certainly in the area of antibiotic stewardship, hospitals can do a lot more,” he told The Hospitalist. “A lot of the most potent antibiotics are being prescribed in the hospital. … If they’re necessary, that’s the way it is. It’s necessary and people are put at increased risk because they had to get those antibiotics. But if they weren’t necessary, it’s all the more critical that greater judiciousness be applied to the use of those antibiotics.”

Since many of the cases had their onset outside the hospital, hospitals must emphasize quick evaluation of admitted patients, including asking them an uncomfortable question: “Have you had diarrhea recently?” Three unformed stools in the previous 24 hours, along with antibiotic use in the previous 12 weeks—particularly the previous four to eight weeks—means a C. diff infection is a distinct possibility.

“We don’t think to ask, and patients may not bring it up because they are embarrassed by it,” Dr. McDonald says. Patients suspected of having C. diff infections must be isolated right away, he adds. (Click here to listen to more of Dr. McDonald's interview.)

The success in lowering the infection rate within the three state initiatives is encouraging, Dr. McDonald says, particularly because almost the entire emphasis in those programs was infection control; only the Massachusetts program included antibiotic stewardship, and only as a minor component.

“It does appear that prevention’s possible,” he notes. “Even more can be done if more tools are brought to bear and brought to bear across settings.”

Ketino Kobaidze, MD, PhD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious-disease-control committees at Emory’s Hospital Midtown, says that while hospitalists have long been aware of C. diff infections in community settings, she was surprised to learn that 75% of cases were found in patients not currently in the hospital.

“This information will make all hospital-based doctors be more alert when a patient comes with diarrhea—and include CDI in their differential,” she says. “We need to change our approach and make appropriate recommendations on how to screen and prevent further spread.

 

“What this data tells us is that we need to educate our doctors to prescribe antibiotics more carefully; ask patients about diarrhea even if they are coming in for another disease; and order diagnostic tests if [they report it].”

SHM presid

ent Joseph Ming-Wah Li, MD, MPH, SFHM, says the findings underscore the need for early identification. “If we don’t identify them early on, we could put them in rooms with other patients who are not currently infected with C. diff and could certainly exacerbate the problem,” he says.

He also says that while it’s widely accepted that antibiotics are overprescribed, the use of antibiotics in agriculture─in the poultry and cattle industries, for example─is an area that should be explored.

“One of the things to think about is the amount of antibiotics that are used for non- healthcare reasons,” he says, “and that also is a very large contributor to the problem.”

Thomas R. Collins is a freelance medical writer in South Florida.

 

A Centers for Disease Control report on Clostridium difficile infections offers encouragement for hospitalists that prevention is possible, but also offers further evidence that more work is needed to prevent the potentially deadly infections.

The report examines three sets of data on C. diff infections. According to an analysis of the CDC’s Emerging Infections Program, 94% of the more than 10,000 infections identified were related to the receipt of healthcare. Also, 75% of the infections had their onset in patients who were not hospitalized at the time.

An analysis of National Healthcare Safety Network data of present-at-admission and hospital-onset C. diff infections found that 52% of the cases involved patients already infected at admission, although they were largely healthcare-related.

And an analysis of data from three state-administered CDI-prevention projects in Illinois, Massachusetts, and New York found that, cumulatively, C. diff infections were reduced by 20%, showing that prevention efforts can pay off.

The heavy involvement of healthcare settings in infections shows that more should be done, says Clifford McDonald, MD, chief of prevention and response in CDC’s Division of Healthcare Quality and Promotion in Atlanta. He took aim specifically at careful use of antibiotics, as broad-spectrum antibiotics kill off bacteria that can help keep C. diff at bay.

“Certainly in the area of antibiotic stewardship, hospitals can do a lot more,” he told The Hospitalist. “A lot of the most potent antibiotics are being prescribed in the hospital. … If they’re necessary, that’s the way it is. It’s necessary and people are put at increased risk because they had to get those antibiotics. But if they weren’t necessary, it’s all the more critical that greater judiciousness be applied to the use of those antibiotics.”

Since many of the cases had their onset outside the hospital, hospitals must emphasize quick evaluation of admitted patients, including asking them an uncomfortable question: “Have you had diarrhea recently?” Three unformed stools in the previous 24 hours, along with antibiotic use in the previous 12 weeks—particularly the previous four to eight weeks—means a C. diff infection is a distinct possibility.

“We don’t think to ask, and patients may not bring it up because they are embarrassed by it,” Dr. McDonald says. Patients suspected of having C. diff infections must be isolated right away, he adds. (Click here to listen to more of Dr. McDonald's interview.)

The success in lowering the infection rate within the three state initiatives is encouraging, Dr. McDonald says, particularly because almost the entire emphasis in those programs was infection control; only the Massachusetts program included antibiotic stewardship, and only as a minor component.

“It does appear that prevention’s possible,” he notes. “Even more can be done if more tools are brought to bear and brought to bear across settings.”

Ketino Kobaidze, MD, PhD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious-disease-control committees at Emory’s Hospital Midtown, says that while hospitalists have long been aware of C. diff infections in community settings, she was surprised to learn that 75% of cases were found in patients not currently in the hospital.

“This information will make all hospital-based doctors be more alert when a patient comes with diarrhea—and include CDI in their differential,” she says. “We need to change our approach and make appropriate recommendations on how to screen and prevent further spread.

 

“What this data tells us is that we need to educate our doctors to prescribe antibiotics more carefully; ask patients about diarrhea even if they are coming in for another disease; and order diagnostic tests if [they report it].”

SHM presid

ent Joseph Ming-Wah Li, MD, MPH, SFHM, says the findings underscore the need for early identification. “If we don’t identify them early on, we could put them in rooms with other patients who are not currently infected with C. diff and could certainly exacerbate the problem,” he says.

He also says that while it’s widely accepted that antibiotics are overprescribed, the use of antibiotics in agriculture─in the poultry and cattle industries, for example─is an area that should be explored.

“One of the things to think about is the amount of antibiotics that are used for non- healthcare reasons,” he says, “and that also is a very large contributor to the problem.”

Thomas R. Collins is a freelance medical writer in South Florida.

 

A Centers for Disease Control report on Clostridium difficile infections offers encouragement for hospitalists that prevention is possible, but also offers further evidence that more work is needed to prevent the potentially deadly infections.

The report examines three sets of data on C. diff infections. According to an analysis of the CDC’s Emerging Infections Program, 94% of the more than 10,000 infections identified were related to the receipt of healthcare. Also, 75% of the infections had their onset in patients who were not hospitalized at the time.

An analysis of National Healthcare Safety Network data of present-at-admission and hospital-onset C. diff infections found that 52% of the cases involved patients already infected at admission, although they were largely healthcare-related.

And an analysis of data from three state-administered CDI-prevention projects in Illinois, Massachusetts, and New York found that, cumulatively, C. diff infections were reduced by 20%, showing that prevention efforts can pay off.

The heavy involvement of healthcare settings in infections shows that more should be done, says Clifford McDonald, MD, chief of prevention and response in CDC’s Division of Healthcare Quality and Promotion in Atlanta. He took aim specifically at careful use of antibiotics, as broad-spectrum antibiotics kill off bacteria that can help keep C. diff at bay.

“Certainly in the area of antibiotic stewardship, hospitals can do a lot more,” he told The Hospitalist. “A lot of the most potent antibiotics are being prescribed in the hospital. … If they’re necessary, that’s the way it is. It’s necessary and people are put at increased risk because they had to get those antibiotics. But if they weren’t necessary, it’s all the more critical that greater judiciousness be applied to the use of those antibiotics.”

Since many of the cases had their onset outside the hospital, hospitals must emphasize quick evaluation of admitted patients, including asking them an uncomfortable question: “Have you had diarrhea recently?” Three unformed stools in the previous 24 hours, along with antibiotic use in the previous 12 weeks—particularly the previous four to eight weeks—means a C. diff infection is a distinct possibility.

“We don’t think to ask, and patients may not bring it up because they are embarrassed by it,” Dr. McDonald says. Patients suspected of having C. diff infections must be isolated right away, he adds. (Click here to listen to more of Dr. McDonald's interview.)

The success in lowering the infection rate within the three state initiatives is encouraging, Dr. McDonald says, particularly because almost the entire emphasis in those programs was infection control; only the Massachusetts program included antibiotic stewardship, and only as a minor component.

“It does appear that prevention’s possible,” he notes. “Even more can be done if more tools are brought to bear and brought to bear across settings.”

Ketino Kobaidze, MD, PhD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious-disease-control committees at Emory’s Hospital Midtown, says that while hospitalists have long been aware of C. diff infections in community settings, she was surprised to learn that 75% of cases were found in patients not currently in the hospital.

“This information will make all hospital-based doctors be more alert when a patient comes with diarrhea—and include CDI in their differential,” she says. “We need to change our approach and make appropriate recommendations on how to screen and prevent further spread.

 

“What this data tells us is that we need to educate our doctors to prescribe antibiotics more carefully; ask patients about diarrhea even if they are coming in for another disease; and order diagnostic tests if [they report it].”

SHM presid

ent Joseph Ming-Wah Li, MD, MPH, SFHM, says the findings underscore the need for early identification. “If we don’t identify them early on, we could put them in rooms with other patients who are not currently infected with C. diff and could certainly exacerbate the problem,” he says.

He also says that while it’s widely accepted that antibiotics are overprescribed, the use of antibiotics in agriculture─in the poultry and cattle industries, for example─is an area that should be explored.

“One of the things to think about is the amount of antibiotics that are used for non- healthcare reasons,” he says, “and that also is a very large contributor to the problem.”

Thomas R. Collins is a freelance medical writer in South Florida.