JAC Advance Access originally published online on March 10, 2006
Journal of Antimicrobial Chemotherapy 2006 57(5):1019-1020; doi:10.1093/jac/dkl075
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Correspondence |
Non-adherence to infectious disease consultations: are surgeons to blame?
University of Nebraska Medical Center—Infectious Diseases, 4242 Farnam Street Suite 145, Omaha, NE 68118, USA
* E-mail: mmadariaga{at}unmc.edu
Keywords: infectious diseases , consultations
Sir,
Pulcini et al.1 reported the compliance with recommendations from infectious disease consultations in a university hospital in France. Despite the fact that the consultations were not specifically requested or initiated by the primary teams, the compliance was as high (>80%) as that reported for specifically requested consultations in a university and public hospitals in the United States.2 Another similar finding in both studies was the fact that compliance was diminished in surgical services. In fact, in Pulcini et al.’s study,1 after multivariate analysis was performed the odds ratio of compliance was 4.9 [95% confidence interval 2.0–12.1, P = 0.001] in ward A (mainly a medical ward) as compared with ward B (a ward managed by the trauma team). In the study that I co-authored,2 the difference was not that pronounced but was still significant. In a logistic regression mixed model we found that the adjusted probability of adherence to recommendations was 79% for medicine and 68% for surgery (odds ratio 1.9, 95% confidence interval 1.2–2.9, P = 0.006). Another study reported from a university hospital in Korea3 regarding compliance with targeted antibiotic (glycopeptides, carbapenems, antipseudomonal cephalosporins and aminoglycosides) advisory consultations described the compliance as being higher in medical services than in surgical services (64.2 versus 43.1%; P = 0.005).
The issue of antibiotic use in surgical wards has caused heated debate. Some surgical units are closed to infectious disease advice and only surgical housestaff have prescribing authority for them.4 In other institutions, surgeons believe that antibiotic drug restriction policies are monopolized by infectious disease physicians, preventing surgical practitioners from taking direct control of important issues related to their own patients.5 Furthermore, at least one study has drastically concluded that ‘medical infectious disease specialists may overtreat common surgical infections with antibiotics' and that ‘surgical infections should be treated by surgeons’.6
I believe with Tenenbaum4 that the importance of an infectious disease consultation goes beyond the proper use of antibiotics and has an ‘aggregated’ value of the clinical expertise of the infectious disease practitioner.
The issue, however, is not who better prescribes antibiotics but how patients will benefit more. At the personal level, physician–physician communication alone may not be sufficient to improve compliance with recommendations;2 a deeper level of trust, cooperation and understanding between infectious diseases specialists and surgeons may be required. At the institutional level, several measures may improve understanding of infectious disease endeavours: participation of surgeons in infection control committees, collaborative efforts by professional societies in the elaboration of guidelines (an excellent example of this are the Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections, conjointly formulated by the Infectious Disease Society of America and the Surgical Infection Society)7 and the active participation of surgeons in infectious disease mini-fellowships or rotations, particularly at the assistant professor level, when surgeons believe they acquire their greatest expertise.8
Transparency declarations
None to declare.
References
1.
Pulcini C, Pradier C, Samat-Long C et al. Factors associated with adherence to infectious diseases advice in two intensive care units. J Antimicrob Chemother 2006; 57: 546–50.
2. Lo E, Rezai K, Evans AT et al. Why don't they listen? Adherence to recommendations of infectious disease consultations. Clin Infect Dis 2004; 38: 1212–8.[CrossRef][Web of Science][Medline]
3. Kim BN. Compliance with an infectious disease specialist's advisory consultations on targeted antibiotic usage. J Infect Chemother 2005; 11: 84–8.[CrossRef][Medline]
4. Tenenbaum MJ. Infectious diseases consultative recommendations: if heard, they can be listened to. Clin Infect Dis 2004; 38: 1219–21.[Medline]
5.
Cohn SM, Fisher BT. Do surgeons have a role as infectious disease consultants? Arch Surg 1996; 131: 990–3.
6. Gorecki PJ, Schein M, Mehta V et al. Surgeons and infectious disease specialists: different attitudes towards antibiotic treatment and prophylaxis in common abdominal surgical infections. Surg Infect (Larchmt) 2000; 1: 115–23.
7. Solomkin JS, Mazuski JE, Baron EJ et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis 2003; 37: 997–1005.[CrossRef][Web of Science][Medline]
8.
Ko CY, Whang EE, Karamanoukian R et al. What is the best method of surgical training? A report of America's leading senior surgeons. Arch Surg 1998; 133: 900–5.
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  C. Pulcini Comment on: Non-adherence to infectious diseases consultations: are surgeons to blame? J. Antimicrob. Chemother., November 1, 2006; 58(5): 1095 - 1095. [Full Text] [PDF]
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