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Telephone consultation inadequate for S. aureus bacteremia

NEW YORK (Reuters Health) – Telephone consultation is an inadequate substitute for bedside infectious disease consultation in managing patients with Staphylococcus aureus bacteremia, a new study shows.

“In serious and complicated infections like S. aureus bacteremia, informal consultation might not be enough,” Dr. Asko Jarvinen from Finland’s Helsinki University Central Hospital told Reuters Health by email. “The treating physician should insist that consultations are based on review of patient records and if needed bedside investigation by the consulting physician…. The threshold to contact the infectious disease specialist (IDS) again should be low.”

In light of the fact that many IDS consultations are informal (by telephone or “curbside”), Dr. Jarvinen and colleagues conducted a retrospective study to analyze the impact of informal IDS consultation on disease progression, outcome, and mortality, compared with formal bedside consultation or no consultation at all.

Among 342 patients with S. aureus bacteremia, 245 cases received IDS bedside consultation, 62 had informal consultations, and 35 were managed without consultation.

The bedside and informal consult groups did not differ in rates of severe sepsis, but patients with no IDS consult at all were significantly more likely to experience severe sepsis, the authors reported online October 19 in Clinical Infectious Diseases.

All patients received an effective antibiotic, but a proper duration of antibiotic therapy was more common with bedside consultation than with either telephone consultation or no consultation. These differences were not statistically significant when patients who died within three days of bacteria onset were omitted, however.

Patients who had bedside IDS consults spent significantly more days in the hospital compared to patients in the other two groups.

And deep infection foci were identified significantly more often with bedside consultation (78%) than when IDS was consulted by phone (53%) or not at all (29%).

In the first three days, having a phone consult or a bedside IDS visit wasn’t linked with mortality risk. But at seven, 28, and 90 days, mortality was significantly lower among patients with bedside consultation.

After adjusting for all prognostic determinants, fatal outcome was significantly associated with no IDS consultation, pneumonia, ICU treatment within three days after bacteremia onset, and corticosteroid therapy. Telephone consultation patients were 2.31-fold more likely to die than were bedside consultation patients.

Bedside consultation was also significantly associated with lower mortality in a separate analysis of ICU-treated patients.

“Informal consultations are certainly one of the most efficient ways to get answers to specific questions,” Dr. Jarvinen said. “However, the medical community has not analyzed situations where informal consultations might be appropriate or should be avoided. S. aureus bacteremia is one of the more complicated situations, and there is perhaps also more to gain with thorough consultations since the effect of IDS consultation on reduction of mortality has been clearly shown.”

“In informal consultations, the consulting ID physician should evaluate if the original question is the right one, are there any other questions to solve, is the information given comprehensive, and also try to get an impression if the answer is understood and how will the treating physician react if the clinical situation is not progressing as expected,” Dr. Jarvinen concluded. “If there is doubt on these issues, telephone consultation might not be the best option.”

Dr. Vivian H. Chu (along with Dr. Daniel J. Sexton) from Duke University Medical Center, Durham, North Carolina, wrote an editorial that was published with the report. In an email, Dr. Chu told Reuters Health, “A significant amount of time is spent obtaining historical and clinical details that are crucial in determining patient outcomes and this time is better spent at the bedside than on the phone. As a general rule, we advise bedside consultation for all patients with S. aureus bacteremia (SAB).”

“We hope that doctors performing informal telephone or email consultations read the study carefully and take reasonable measures to attempt to avoid the poor outcomes of patients with SAB who receive telephone consultations,” Dr. Chu said. “For example, it would be useful to routinely inform doctors requesting telephone or informal consultations that management of SAB involves considerably more than picking an effective drug, ordering an echocardiogram, and deciding on an appropriate duration of therapy. Serial clinical examinations and a careful assessment of the patient’s response to treatment (as measured by resolution of fever and bacteremia) have a crucial impact on subsequent decisions.”

“For hospitals that do not have ID specialists on staff, telemedicine may provide an option for patients with SAB and other serious infectious diseases,” Dr. Chu added. “However the technology for such consultations is imperfect and the impact and relative benefit of such interactions have not been adequately studied. Further studies examining the relative benefit of consultation via telemedicine as compared to telephone consultations are needed.”

Dr. David L. Smith from University of Mississippi School of Medicine in Flowood also commented on the study for Reuters Health.

“There is no such thing as a telephone ‘consultation’ in medicine,” Dr. Smith said in an email. “A consultation requires that the consulting physician examine the medical record, directly examine the patient, and make recommendations as to care and treatment in the medical record. The only exceptions to this rule are in emergency situations–wartime, natural disasters, etc., in which transport of the patient is not possible. Even in this situation–a physician is giving advice not a consultation. Yes it is inadequate–especially in an entity which carries a 20-40% mortality.”

SOURCE: http://bit.ly/Wg7VdB

Clin Infect Dis 2012.