Got reamed for not consulting Infectious Disease

[aspergilloma]

Old COPDer intubated in the field for rapid decompensation after <12hrs of dysuria/fever.
2 peripheral blood cultures drawn <2hrs after intubation. Treated empirically with vanc/zosyn, gets rapidly better and extubated/headed to the floor within 24hrs of admission. vanco pulled off and narrowed to CTX due to:

-urine growing pan-sensitive e. coli.
-1 of the 2 blood cultures bottles growing strep mitis. other bottle is NGTD at 72hrs.
-CXR clear, no risk factors or history that would be consistent with endocarditis. She has dentures.

I attributed the strep mitis to either "contamination or transient bacteremia following intubation". didn't feel strongly about working it up but went ahead and drew a second set of cultures to verify that she stayed negative after narrowing to CTX to cover the UTI e. coli.

Attending was adamant about getting ID's clearance re: the strep.


Was I way off base on this one? I never would've consulted ID had I been on my own

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[sluggs]

Think you were good on that one!

 

[deleted171991]

It never hurts to ask when unsure. So your attending wasn't way off base either. I actually tend to respect people who know what they don't know, and ask.

 

[jdh71]

Old COPDer intubated in the field for rapid decompensation after <12hrs of dysuria/fever.
2 peripheral blood cultures drawn <2hrs after intubation. Treated empirically with vanc/zosyn, gets rapidly better and extubated/headed to the floor within 24hrs of admission. vanco pulled off and narrowed to CTX due to:

-urine growing pan-sensitive e. coli.
-1 of the 2 blood cultures bottles growing strep mitis. other bottle is NGTD at 72hrs.
-CXR clear, no risk factors or history that would be consistent with endocarditis. She has dentures.

I attributed the strep mitis to either "contamination or transient bacteremia following intubation". didn't feel strongly about working it up but went ahead and drew a second set of cultures to verify that she stayed negative after narrowing to CTX to cover the UTI e. coli.

Attending was adamant about getting ID's clearance re: the strep.


Was I way off base on this one? I never would've consulted ID had I been on my own

I wouldn't have called ID on that either.

 

[Doctor4Life1769]

I wouldn't consult either. 1/2 usually is contaminant and if concerned then get repeat blood cultures. Patient is improving. If wasn't then I would consult

 

[aspergilloma]

His argument was that an anaerobe is an unusual contaminant.

had she not had a Mac in her edentulous mouf 2 hrs before the cultures were drawn, I could see his point.

 

[tartesos]

Old COPDer intubated in the field for rapid decompensation after <12hrs of dysuria/fever.
2 peripheral blood cultures drawn <2hrs after intubation. Treated empirically with vanc/zosyn, gets rapidly better and extubated/headed to the floor within 24hrs of admission. vanco pulled off and narrowed to CTX due to:

-urine growing pan-sensitive e. coli.
-1 of the 2 blood cultures bottles growing strep mitis. other bottle is NGTD at 72hrs.
-CXR clear, no risk factors or history that would be consistent with endocarditis. She has dentures.

I attributed the strep mitis to either "contamination or transient bacteremia following intubation". didn't feel strongly about working it up but went ahead and drew a second set of cultures to verify that she stayed negative after narrowing to CTX to cover the UTI e. coli.

Attending was adamant about getting ID's clearance re: the strep.


Was I way off base on this one? I never would've consulted ID had I been on my own

You did all the right steps. Your staff was scared because strep is not a usual contaminant and may need more work up if persistently positive and you can't find a source, but you had one and any cephalosporin to treat the ecoli would have taken care of it as well.

I wouldn't have called ID either fwiw.


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[Doctor Bob]

The entire specialty of infectious diseases could be replaced by judicious use of a Sanford Guide.

 

[engineeredout]

Can't imagine being an ID consultant. Nothing infuriates me more than seeing an ID consult for "UTI, Sepsis", and I'm not even the one that has to do the consult.

 

[tartesos]

The entire specialty of infectious diseases could be replaced by judicious use of a Sanford Guide.

You could be replaced by a Washington manual.
Generalizations like this make me think you are either trolling or a jerk, pick one.


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[Hernandez]

I doubt I'd have called ID for that unless I really thought I was missing something. Especially if I didn't like the ID

 

[Doctor Bob]

You could be replaced by a Washington manual.
Generalizations like this make me think you are either trolling or a jerk, pick one.

I'll go for being a jerk; I've never denied that.

In all the go-arounds I've had to endure on the ID service, 99% of the consults are for questions that the primary service could have answered by opening a sanford guide. Questions about duration of antibiotic treatment, or questions about "what antibiotic should we try now since they've grown a new bug". If the primary service just referred to the guide (it's intended purpose), then they wouldn't need to make the consult in the first place.

ID docs are needed at the quaternary referral centers for treatment of the newly emerged MDROs, in the outpatient clinics for HIV/TB management, etc, etc. They aren't needed in the vast majority of community hospitals for management of osteomyelitis/bacteremia/line infections, and the other multitude of things they get consulted for. That's just generalists being lazy.

And could I be replaced by a Washington manual? I should hope so since I helped write one of them...

 

[deleted171991]

Doctor Bob is right, so can we fire some of the ID docs, please, so they won't have to twiddle their thumbs while waiting for the next TB patient? We have enough antibiotic police already in our hospitals.

This is what being employees and/or poorly reimbursed does to people. Twenty years ago, they would have loved to be consulted even for a common cold, if it was a young well-insured patient.

Unfortunately, we live in a period of high malpractice risks and vastly increasing medical knowledge, so even the best generalists will ask for help with things they are not experienced with. I have seen cardiologists who refused severely decompensated CHF patients because the patient had concomitant DKA (both related to a period of stress), and they were not "comfortable" managing an insulin drip.

During my fellowship, one of my old and wise attendings said, in a similar situation: "You'll want people to feel comfortable and not cringe, when calling you for a consult. It's good for you and it's good for the patients. Don't chastise them if they don't know something trivial, because then they won't call you even for something important."

 

[tartesos]

I'll go for being a jerk; I've never denied that.

In all the go-arounds I've had to endure on the ID service, 99% of the consults are for questions that the primary service could have answered by opening a sanford guide. Questions about duration of antibiotic treatment, or questions about "what antibiotic should we try now since they've grown a new bug". If the primary service just referred to the guide (it's intended purpose), then they wouldn't need to make the consult in the first place.

ID docs are needed at the quaternary referral centers for treatment of the newly emerged MDROs, in the outpatient clinics for HIV/TB management, etc, etc. They aren't needed in the vast majority of community hospitals for management of osteomyelitis/bacteremia/line infections, and the other multitude of things they get consulted for. That's just generalists being lazy.

And could I be replaced by a Washington manual? I should hope so since I helped write one of them...

ID goes way beyond a Sanford guide my friend, and as I am boarded in infectious diseases I can attest to that, you make good points, and a lot of those issues an internist should be able to handle.
Let's just agree to disagree on this and put it to rest.

Sorry I called you a jerk/troll... but you did hit a nerve( no excuse).


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[jdh71]

I like ID for complicated infections. NTMB. Anything that will require long courses of IV abx in the out patient setting. Fungal infections. Anything viral.

I like the stamp of their opinion on top of my liability in these cases.

And sure Vanc/Zosyn made a lot of critical care easier, but there is much much much more out there.