[Impact of an infectious diseases consultation service on the quality of care and the survival of patients with infectious diseases]

[Development and validation of potential structure indicators for clinical infectious disease (ID) care in German hospitals during the COVID-19 pandemic]

INTRODUCTION

This study describes the development and validation of structure indicators for clinical infectious disease (ID) care in German hospitals, which is important to adequately face the future challenges in ID medicine.

METHODS

A team of experts developed the structure indicators in a three-stage, multicriteria decision-making process: (1) identification of potential structure indicators based on a literature review, (2) written assessment process, and (3) face-to-face discussion to reach consensus and final selection of appropriate structure indicators. A field study was conducted to assess the developed structure indicators. A score based on the structure indicators was determined for each hospital and validated via receiver operator characteristic (ROC) curves using externally validated ID expertise (German Society of ID (DGI) Centre).

RESULTS

Based on a list of 45 potential structure indicators, 18 suitable indicators were developed for clinical ID care structures in German hospitals. Out of these, ten key indicators were defined for the general and coronavirus disease 2019- (COVID-19-) specific clinical ID care structures. In the field survey of clinical ID care provision for COVID-19 patients in 40 German hospitals, the participating facilities achieved 0 to 9 points (median 4) in the determined score. The area under the ROC curve was 0.893 (95% CI: 0.797, 0.988; p < 0.001).

DISCUSSION/CONCLUSION

The structure indicators developed within the framework of a transparent and established development process can be used in the future to both capture the current state and future developments of ID care quality in Germany and enable comparisons.

The impact of infectious diseases consultation on the management and outcomes of Pseudomonas aeruginosa bacteraemia in adults: a retrospective cohort study

BACKGROUND

Pseudomonas aeruginosa bacteraemia (PAB) is associated with high mortality. The benefits of infectious diseases consultation (IDC) has been demonstrated in Staphylococcal aureus bacteraemia and other complex infections. Impact of IDC in PAB is unclear. This study aimed to evaluate the impact of IDC on the management and outcomes in patients with PAB.

METHODS

This is a retrospective cohort single-centre study from 1 November 2006 to 29 May 2019, in all adult patients admitted with first episode of PAB. Data collected included demographics, clinical management and outcomes for PAB and whether IDC occurred. In addition, 29 Pseudomonas aeruginosa (PA) stored isolates were available for Illumina whole genome sequencing to investigate if pathogen factors contributed to the mortality.

RESULTS

A total of 128 cases of PAB were identified, 71% received IDC. Patients who received IDC were less likely to receive inappropriate duration of antibiotic therapy (4.4%; vs 67.6%; p < 0.01), more likely to be de-escalated to oral antibiotic in a timely manner (87.9% vs 40.5%; p < 0.01), undergo removal of infected catheter (27.5% vs 13.5%; p = 0.049) and undergo surgical intervention (20.9% vs 5.4%, p = 0.023) for source control. The overall 30-day all-cause mortality rate was 24.2% and was significantly higher in the no IDC group in both unadjusted (56.8% vs 11.0%, odds ratio [OR] = 10.63, p < 0.001) and adjusted analysis (adjusted OR = 7.84; 95% confidence interval, 2.95-20.86). The genotypic analysis did not reveal any PA genetic features associated with increased mortality between IDC versus no IDC groups.

CONCLUSION

Patients who received IDC for PAB had lower 30-day mortality, better source control and management was more compliant with guidelines. Further prospective studies are necessary to determine if these results can be validated in other settings.

Impact of Infectious Disease Consultation in Patients With Candidemia: A Retrospective Study, Systematic Literature Review, and Meta-analysis

BACKGROUND

Morbidity and mortality from candidemia remain unacceptably high. While infectious disease consultation (IDC) is known to lower the mortality from Staphylococcus aureus bacteremia, little is known about the impact of IDC in candidemia.

METHODS

We conducted a retrospective observational cohort study of candidemia patients at a large tertiary care hospital between 2015 and 2019. The crude mortality rate was compared between those with IDC and without IDC. Then, we systematically searched 5 databases through February 2020 and performed a meta-analysis of the impact of IDC on the mortality of patients with candidemia.

RESULTS

A total of 151 patients met the inclusion criteria, 129 (85%) of whom received IDC. Thirty-day and 90-day mortality rates were significantly lower in the IDC group (18% vs 50%; P = .002; 23% vs 50%; P = .0022, respectively). A systematic literature review returned 216 reports, of which 13 studies including the present report fulfilled the inclusion criteria. Among the 13 studies with a total of 3582 patients, IDC was performed in 50% of patients. Overall mortality was 38.2% with a significant difference in favor of the IDC group (28.4% vs 47.6%), with a pooled relative risk of 0.41 (95% CI, 0.35-0.49). Ophthalmology referral, echocardiogram, and central line removal were performed more frequently among patients receiving IDC.

CONCLUSIONS

This study is the first systematic literature review and meta-analysis to evaluate the association between IDC and candidemia mortality. IDC was associated with significantly lower mortality and should be considered in all patients with candidemia.

Serologic screening and infectious disease consultation (IDC): Indicated in heart, lung, liver (HLL) solid organ transplants (SOT) for measles, mumps, rubella, and varicella

BACKGROUND

Solid organ transplant (SOT) recipients are a special group of patients who require comprehensive evaluation for preventable infectious diseases before transplantation. The main aim of our study was to investigate the number of heart, lung, and liver (HLL) transplant recipients who were evaluated for their immune status against measles, mumps, rubella (MMR), and varicella (VZV). As a secondary aim, we investigated whether pre-transplant infectious disease consultation (IDC) improves vaccination rates.

METHODS

This study was an institution-based retrospective analysis of HLL transplant recipients born in or after 1957 and evaluated at Mayo Clinic, FL Transplant Center between January 1st, 2016 and December 31st, 2017. Data collection was obtained from electronic medical records. The vaccination rates were compared by univariate analysis based on IDC and no ID consultation (NIDC).

RESULTS

One hundred and eighty-seven (77%) of a total 242 patients received an IDC pre-transplantation. Varicella IgG levels were screened in all 187 IDC candidates. Among the 187 IDC patients, mumps, measles, and rubella IgG serologies were performed in 9 (5%), 21 (11%), and 51 (27%), respectively. Among all 242 patients, vaccines given included 2 (0.8%) MMR, 10 (4.1%) varicella and 85 (35.12%) Zostavax. Univariate analysis revealed that Zostavax was given to 76 (40.6%) pre-transplant IDC patients and only in 9 (16.7%) NIDC patients (P < .001).

CONCLUSIONS

Despite the relatively high IDC rate, patients' screened numbers for MMR IgG levels were low. Results pointed out the need for MMR protocol-driven serologic screening as well as for VZV and IDC prior to transplantation to increase vaccination rates.

Mortality attributable to hospital acquired infections with multidrug-resistant bacteria in a large group of German hospitals

BACKGROUND

According to extrapolations, around 35,000 patients in Germany develop hospital acquired infections (HAI) with a multidrug-resistant organism (MDRO) every year, and about 1500 of them die. Previous estimations were based on laboratory data and prevalence studies. Aim of this study was to establish the incidences of hospital acquired MDRO infections and the resulting deaths by expert review.

METHODS

Data on patients suffering from a hospital acquired MDRO infection were collected from 32 hospitals from all care levels. Records of patients with MDRO infection who died in the year 2016 underwent an onsite review by two experts to determine the impact of the infection, if any, on the cause of death.

RESULTS

A total of 714,108 in-patients were treated in 32 hospitals participating in the study. Of these patients, 1136 suffered a hospital acquired MDRO infection (1.59 per 1000 patients). 215 patients with an MDRO infection died [0.301 per 1000, (95% CI 0,261-0,341)], but only in 78 cases this was estimated as the cause of death [0.109 per 1000 patients (95% CI 0.085-0.133)].

CONCLUSION

By putting the above rates in relation to the total number of in-patients in Germany, it can be rated that around 31,052 patients per year suffer a hospital acquired MDRO infection, and 2132 patients die from it. These results from our reviewer investigation confirm earlier extrapolations.

Impact of infectious diseases consultation as a part of an antifungal stewardship programme on candidemia outcome in an Italian tertiary-care, University hospital

Candidemia is a major cause of in-hospital mortality. Antifungal stewardship programme (AFSP) providing infectious diseases consultation (IDC) might improve the outcome. We evaluate the impact on candidemia mortality of IDC as part of AFSP restricting the use of all antifungals with exception of fluconazole. We retrospectively reviewed the charts of patients with documented candidemia in our hospital during the period 2012-2014 evaluating the impact of several variables on 30-days in-hospital mortality. We reviewed data on 276 patients with documented candidemia: 200 (72%) were treated without IDC and 76 (28%) with IDC. In the group without IDC, 52 patients (26%) received no antifungal therapy. Antifungals used for treating candidemia were (no IDC/IDC): azoles (74%/42%); echinocandins (0%/46%); liposomal and lipidic complex amphotericin B (0%/12%). The 30-day in-hospital mortality was respectively (no IDC/IDC) 37% vs. 20% (p = 0.011). The multivariate analysis confirmed IDC as independent factor protecting from death (OR 0.511, 95% CI 0.251-0.994; p = 0.046), together with fungemia due to non-albicans Candida (OR 0.565, 95% CI 0.327-0.977; p = 0.042). Age >65 years was associated with a higher risk of death (OR 1.989, 95% CI 1.055-3.895; p = 0.038). The additional cost for the use of echinocandins driven by IDC in the study period was €207,000. IDC, as a part of a restrictive front-end antimicrobial stewardship programme (ASP), providing a timely right choice of antifungal therapy, increases the cost of antifungal drugs but might be a contributing protective factor from mortality due to candidemia. Efforts to increase the number of IDC in patients with candidemia seems to be warranted.

Clinical and economic burden of infections in hospitalized solid organ transplant recipients compared with the general population in Canada - a retrospective cohort study

Infections continue to be a major cause of post-transplant morbidity and mortality, requiring increased health services utilization. Estimates on the magnitude of this impact are relatively unknown. Using national administrative databases, we compared mortality, acute care health services utilization, and costs in solid organ transplant (SOT) recipients to nontransplant patients using a retrospective cohort of hospitalizations in Canada (excluding Manitoba/Quebec) between April-2009 and March-2014, with a diagnosis of pneumonia, urinary tract infection (UTI), or sepsis. Costs were analyzed using multivariable linear regression. We examined 816 324 admissions in total: 408 352 pneumonia; 328 066 UTI's; and 128 275 sepsis. Unadjusted mean costs were greater in SOT compared to non-SOT patients with pneumonia [(C$14 923 ± C$29 147) vs. (C$11 274 ± C$18 284)] and sepsis [(C$23 434 ± C$39 685) vs. (C$20 849 ± C$36 257)]. Mortality (7.6% vs. 12.5%; P < 0.001), long-term care transfer (5.3% vs. 16.5%; P < 0.001), and mean length of stay (11.0 ± 17.7 days vs. 13.1 ± 24.9 days; P < 0.001) were lower in SOT. More SOT patients could be discharged home (63.2% vs. 44.3%; P < 0.001), but required more specialized care (23.5% vs. 16.1%; P < 0.001). Adjusting for age and comorbidities, hospitalization costs for SOT patients were 10% (95% CI: 8-12%) lower compared to non-SOT patients. Increased absolute hospitalization costs for these infections are tempered by lower adjusted costs and favorable clinical outcomes.

Infectious disease services: a survey from four university hospitals in Germany

PURPOSE

Involvement of infectious disease (ID) specialists in the care of hospitalized patients with infections through consultation services improves the quality of care and the outcome of patients. This survey aimed to describe activities and utilization of ID consultations at four German tertiary care hospitals.

METHODS

A 1-month (March 2016) retrospective cross-sectional study at four university hospitals (Freiburg, Jena, Cologne and Regensburg) was performed. Only ID consultations with written documentation and bedside patient evaluation were included. Consultations were analyzed with regard to requesting departments, infections, case severity, and diagnostic and therapeutic recommendations.

RESULTS

In the study period, 638 ID consultations were performed in 479 patients-corresponding to 3-4 consultations per 100 inpatient cases. Patients were characterized by a high disease complexity-the mean case mix index in patients with consultation was 10.1 compared to 1.6 for all patients. ID consultations were requested by many different specialties, with approximately half of the requests coming from surgical disciplines. ID consultations resulted in revised diagnoses in 34% of the cases, provided recommendations for additional diagnostic procedures in 66%, and for modifications of antimicrobial regimens in 70% of the cases.

CONCLUSIONS

Infectious disease consultations were requested for patients with severe and complicated diseases and resulted in recommendations that highly impacted the diagnostic work-up and therapeutic management of patients. The results of this survey may help to estimate requirements for establishment of such services in Germany.

Infectious diseases consultations can make the difference: a brief review and a plea for more infectious diseases specialists in Germany

Trained infectious diseases (ID) specialists are an integral part of inpatient and outpatient care in many countries, however, these specialized services are established only in selected tertiary care hospitals in Germany. This review summarises studies that addressed the impact of ID consultation services on patient care and outcome. Extensive data for a clinical benefit is available in the context of Staphylococcus aureus bacteremia (SAB), in which in-hospital or 30-day mortality was significantly reduced by 40-50 % in patients evaluated and treated in cooperation with ID consultants. This effect was associated with improved adherence to quality-of-care standards. Moreover, newer studies show a reduced length of hospital stay due to ID consultations, especially if patients are evaluated early in the course of their hospital stay. Of note, informal consultations do not seem to be equivalent to a formal ID consultation with bedside patient evaluation. Studies in other patient groups (solid organ transplant recipients or intensive care unit patients) or in the context of other infections (infective endocarditis, pneumonia, other bloodstream infections) also revealed positive effects of ID consultations. Higher rates of appropriate empirical and targeted antimicrobial treatments and de-escalation strategies due to successful pathogen identification were documented. These modifications resulted in lower treatment costs and decreased antimicrobial resistance development. Although there are methodological limitations in single studies, we consider the consistent and reproducible positive effects of ID consultations shown in studies in different countries and health care systems as convincing evidence for improved quality-of-care and treatment outcomes in patients with infectious diseases. Thus, we strongly recommend efforts to establish significantly more ID consultation services in hospitals in Germany.

[Infectious diseases as a clinical specialty in Germany and Europe]

Clinical infectious diseases have only slowly been established as a medical specialty in Germany. The density of infectious diseases (ID) specialists and the number of ID divisions in general hospitals is still limited when compared with the situation in many other European countries, and there is also a lack of hospital-based medical microbiologists and infection control doctors for many reasons. Often, there is a lack of understanding of the roles and the performance of ID specialists versus microbiologists. Experience in other countries shows that ID specialists are important as clinical experts at the bedside, can help ascertain healthcare quality and patient safety, and are perfectly suited for undertaking strategic tasks in the field of cost-effective antimicrobial therapy algorithms and antibiotic stewardship (ABS) in hospitals. ID specialists are responsible for infection control in several countries, can improve the utility of diagnostic microbiology and are key partners in translational research. We estimate that more than 1,000 additional ID specialists are needed in this country, and believe that specially trained ABS experts can take over parts of their responsibilities and tasks in smaller hospitals. More capacity and flexibility in postgraduate training in infectious diseases, antibiotic stewardship and infection control in Germany will be critical to address the problem of antimicrobial resistance. (As supplied by publisher).