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Abstract & Commentary
Synopsis: An infectious diseases specialist can discharge patients with infections earlier than other physicians providing hospital care.
Source: Eron LJ, Passos S. Early discharge of infected patients through appropriate antibiotic use. Arch Intern Med. 2001;161:61-65.
Eron and passos set out to assess the value of an infectious diseases specialist (IDS) in being able to discharge patients early. They studied 111 patients admitted by the IDS and compared them with 112 patients admitted by internal medicine specialists (IMS) during 1998 and 1999 at the Kaiser Hospital in Honolulu, Hawaii. The diagnoses selected for comparisons included cellulitis, community-acquired pneumonia (CAP), and urinary tract infections (UTI).
The outcomes measures included whether a patient was readmitted with the same diagnosis within 30 days and a patient survey inquiring about patient satisfaction with care and return to activities of daily living. The questionnaire was mailed a month after discharge with approximately 80% returned.
The differences between the IDS and IMS were striking for length of hospital stay. IDS-managed patients had a 2.5 day shorter stay for cellulitis (0.4 vs 2.9 days), 1.2 day shorter stay for CAP (2.0 vs 3.2), and 1.2 day reduction for UTIs (1.5 vs 2.7). The readmission rates were low for both groups (1 for the IM, 0 for the IDS). Patient satisfaction and return to activities of daily living, however, were better with the IDS. IDS patients even returned to work 1.7 days earlier. It was also noted that the shorter the hospital stay, the more satisfied patients were with care.
Antibiotic use was also different between the IDS and IMS. The IDS was more likely to use outpatient parenteral antimicrobial therapy (OPAT). The IDS also switched from intravenous to oral antibiotics earlier. In terms of specific antibiotics used, the IDS used inpatient clindamycin and outpatient ceftriaxone more for cellulitis whereas the IMS used cephalexin more for outpatients. For UTIs, the IMS used ceftriaxone more in the hospital whereas the IDS used more ciprofloxacin. For CAP, the IDS always used a combination of ceftriaxone plus a macrolide or doxycycline in the hospital followed by doxycycline or a macrolide alone on discharge. The IMS usually used a combination of ceftriaxone plus a macrolide more often than amoxicillin/clavulanate on discharge.
Eron and Passos attribute the early discharge rates and good outcomes to appropriate antibiotic use and the experience of the IDS in dealing with serious infections.
COMMENT BY ALAN D. TICE, MD, FACP
Eron has made a strong statement about what a physician can do to reduce hospital days. He has taken his skills and knowledge as an IDS and applied them to early hospital discharge. He has gone beyond the usual teaching that a patient should be afebrile for at least a day before discharge. Where that rule originated is unclear, but it may not be relevant to modern medicine and is likely not based on any scientific information or outcomes studies. It turns out even fever at the time of discharge does not appear to result in a bad outcome. All patients did well, especially with early discharge. The numerical power of the study is relatively low, and the outcome indicator of readmission is so low that it is not possible to talk of statistical analysis. Whether problems would be recognized by studying a larger number of patients is possible but unlikely.
Why the IDS was able to discharge patients so much earlier than IMS is not clear, but it is likely due to the knowledge and experience of the IDS with serious infections as well as OPAT. Whether the choice of antibiotics really made a difference is not certain. The total duration of therapy with antibiotics was not noted. The route of administration of the antibiotics did not seem to be related to outcomes, but OPAT did allow hospital-level of therapy with early discharge to the OPAT program at Kaiser. Switch therapy to oral antibiotics was also sooner with the IDS but provides a minimal cost savings compared to hospital care or even to OPAT if a day in the hospital can be saved with OPAT.
The finding that patients were happier with care and returned to work earlier if they were sent home earlier was not expected although this has been noted before by Fine and associates.1
OPAT appeared to be an important factor in early hospital discharge and was used more by the IDS than the IMS even though it was equally available to both. This may be a matter of familiarity or comfort with the procedures or intravenous antibiotics delivered in an outpatient setting. The outpatient facilities were the same. Eron is one of the pioneers in OPAT and a strong proponent.2 In another Fine article, it was estimated that patients with CAP could be discharged 2.5 days earlier if there was ready access to OPAT and the doctors had thought of it.3 A recent article by Bradley and associates indicates even children with ruptured appendices can be sent home early on IV antibiotics once surgery has been performed.4
This study may be criticized based on the small number of patients or the limited number of physicians caring for them. Other IDS may not have the same confidence in early discharge plans or the OPAT resources that Eron has.
Early discharge may not be appropriate without good home care or outpatient facilities. The resources available for outpatient care at the Kaiser Hospital are excellent and allow an easy transition from inpatient to outpatient care. They consist of an infusion center model with patients coming in for a few hours every day for the infusions. The clinic meets the guidelines established by the Infectious Diseases Society of America.5
Eron has made a good point about the potential value of the IDS as a "hospitalist" in discharging patients early, but he also makes an important point about the IDS as an "outpatientist" as well in that he continues to follow patients after discharge. He provides the safety net and resources for excellent patient care for patients with serious infections outside the hospital as well. This kind of approach demonstrates the potential economic benefits of early IDS consultations in the hospital, even if it is for early discharge planning for OPAT.
1. Fine MJ, et al. Medical outcomes or ambulatory and hospitalized low risk patients with community-acquired pneumonia. J Gen Intern Med. 1994;(suppl 2):29.
2. Poretz DM, et al. Intravenous antibiotic therapy in an outpatient setting. JAMA. 1982;248:336-339.
3. Fine MJ, et al. The hospital discharge decision for patients with community-acquired pneumonia. Arch Intern Med. 1997;157:47-56.
4. Bradley JS, et al. Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis. Pediatr Infect Dis J. 2001;20:19-24.
5. Williams DN, et al. Practice guidelines for community-based parenteral anti-infective therapy. IDSA Practive Guidelines Committee. Clin Infect Dis. 1997;25(4):