ID consults

[europeman]

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When do you call ID consults?

At the institution I'm at, most of the surgeons (residents and attendings) really have no facility at all with antibiotics, and ID consults are called for almost any patient who has any type of complication. Post op UC patient with leak gets ID consult. The entire SICU is followed by ID. Intra-abdominal abscess patient = ID consult.

Any one else use ID like this at their institution?

We do a community hospital one month rotation to see what it's like, and honestly, it was even worse over there. Even patients with perf'd appencitis would off the bat get an ID consult.

 

[Smurfette]

No, that sounds pretty unusual. We normally reserve ID consults for complicated patients or patients needing restricted Abx. Routine things and common post op infections don't get ID consults unless there are true indications for it (i.e. MDR, not improving despite appropriate regimen, allergies to every drug class, etc.).

Only patients that routinely got ID consults where I trained were transplant patients with an infection.

 

[SouthernSurgeon]

No, that sounds pretty unusual. We normally reserve ID consults for complicated patients or patients needing restricted Abx. Routine things and common post op infections don't get ID consults unless there are true indications for it (i.e. MDR, not improving despite appropriate regimen, allergies to every drug class, etc.).

Only patients that routinely got ID consults where I trained were transplant patients with an infection.

Agreed. The other time when we "always" get ID consults is for a patient who will need long-term IV antibiotics...ID will follow them, monitor their labs, and see them in clinic as outpatients so they get a default consult.

 

[maxheadroom]

I probably over-use ID a bit, but my knowledge of "best practices" in that kind of stuff has declined in the past few years. If a patient has multiple "allergies," has an unusual infection, or has a weird bug, I'll ask ID to follow. The ID guys at my current institution are pretty nice about that stuff and I have tremendous appreciation for their service.

 

[ESU_MD]

anytype of postop wound infection, especially if theres vascular graft, device or transplant involved is ID consult.

routine appy or cholecystitis wasnt a consult.

theres nothing wrong with good multidisciplinary care and I think its better to have them involved.

 

[dynx]

When do you call ID consults?

At the institution I'm at, most of the surgeons (residents and attendings) really have no facility at all with antibiotics, and ID consults are called for almost any patient who has any type of complication. Post op UC patient with leak gets ID consult. The entire SICU is followed by ID. Intra-abdominal abscess patient = ID consult.

Any one else use ID like this at their institution?

We do a community hospital one month rotation to see what it's like, and honestly, it was even worse over there. Even patients with perf'd appencitis would off the bat get an ID consult.

Sounds a little excessive.
We would consult for a patient with foreign material and resistance if we were not planning on removing the material.
Some MDR organisms (ESBL, VREs) are an automatic consult not that we necessarily need it but the hospital instituted a policy. If the micro lab results pop-up the system somehow notifies ID and they come knocking. I think its an attempt to have uniform management of these patients to avoid further problems.
I would never contact ID for something before sensitivities are back and I knew it was a problem beyond a simple infection/fluid collection.

 

[SLUser11]

When do you call ID consults?

At the institution I'm at, most of the surgeons (residents and attendings) really have no facility at all with antibiotics, and ID consults are called for almost any patient who has any type of complication. Post op UC patient with leak gets ID consult. The entire SICU is followed by ID. Intra-abdominal abscess patient = ID consult.

Any one else use ID like this at their institution?

We do a community hospital one month rotation to see what it's like, and honestly, it was even worse over there. Even patients with perf'd appencitis would off the bat get an ID consult.

In St. Louis, ID consults were required if you wanted to write for certain antibiotics (e.g. Meropenem for >48 hours). In Wichita, this was not the case, and we very rarely consulted ID for anything.

Calling ID for anastomotic leaks and intra-abdominal abscesses is ridiculous.

I think a good time to call ID is if there's a C diff toxic megacolon patient that's almost needing a colectomy....IVIG and Fecal enemas are ID territory.

Of course, I've now seen 2 really good articles on diverting loop ileostomies and colonic lavage as opposed to subtotal colectomy, so maybe we'll go straight to the OR and skip the awkwardness of asking for poop donations.

 

[Smurfette]

Interesting...you've actually ordered fecal enemas? They were banned at my residency hospitals (the argument was for sanitary and health reasons of hospital staff, IIRC) and I cannot imagine offering it to a patient now that I'm in PP, let alone getting the necessary donation. Bad C.diff was also an ID consult where I trained, but not for the average case.

 

[SLUser11]

Interesting...you've actually ordered fecal enemas? They were banned at my residency hospitals (the argument was for sanitary and health reasons of hospital staff, IIRC) and I cannot imagine offering it to a patient now that I'm in PP, let alone getting the necessary donation. Bad C.diff was also an ID consult where I trained, but not for the average case.

I have, but the process of "fecal transplant" is very difficult. Usually the patient is sick, and the situation is time sensitive, and there's usually not a plethora of volunteers/donors. If you can get it done in a hurry, though, it is pretty effective.

The colectomy is just so morbid that I've tried alternative routes...however, I still end up being aggressive with the colectomy because I'm a firm believer that the only time it's effective is if it's early in the toxic process. This is exactly why I like the idea of diverting ileostomy with colonic lavage. I know I read one article before, and then I read a second one in this month's annals (Pittsburgh). I'm not ready to change my practice, but I'm definitely intrigued....

 

[dpmd]

It is very rare that we will consult ID at my hospital. There aren't many restricted antibiotics that are commonly needed, and those that are we can also get by talking with pharmacy (and we have an excellent clinical pharmacist that I run stuff past fairly often). Usually it is a patient that was on medicine that we are now taking over. The ID consult from before we came on isn't likely to just go away and we never really try to get rid of them. They always want to do crazy stuff like swab a wound that has been open for a while. I'm trying to think of any that I have called since starting chiefdom in June (we switch over early) and can't think of one. Didn't even call one with my infected ax bifem graft patient but that was mostly because I didn't want to deal with them arguing for us to take out the graft-which I presumed they would do (talked to the clinical pharmacist instead and patient is doing well so far). Not that I think I know all about antibiotic therapy, but I just feel that for most stuff what I do know plus looking at a good info source will be sufficient.

 

[ESU_MD]

Its not so much that surgeons "dont know about antibiotics"
but rather I think its helpful for a few reasons:
-usually if its a case of a leak or abscess, that can be perceived as a complication and I think it helps to diffuse the situation and let the patient think that we are getting other specialists involved to help. who knows it may help in a lawsuit or avoid one.
-another reason would be to have someone checking all the mundane cultures etc daily
-these guys are more up to date on the latest literature too on duration of tx and proper agents, (although I guess we could look it up in stanford guide too if necessary)
-probably the most important is that the ID service usually has multiple PAs to write all the scrips
-of course these ID guys are CONSULTANTS and a good surgeon always monitors what they and the other CONSULTANTS are recommending.
-in private practice its not as big of a deal since everyone is on the take and there arent any residents who have to call consults or see them at 5pm. when you can see it in the morning and bill for it, i think its a different story.

 

[europeman]

ESU, thanks for your message. Let me respond to your comments in sections.

At my institution, surgeons definitely are NOT comfortable with antibiotics. Further, many of them have many misconceptions about their use, when to prescribe what, and for what duration. Consults have recome so routine for anything but the most basic surgical infections (routine appy/chole), that through the years, the surgeons really have lost facility in this skill. Since no surgical faculty at my institution have an interest in surgical infections, this sort of mind-set has spread into the residents who likewise have no facility.

Regarding intra-abdominal leak/abscess and calling an ID consults for that.... I agree with SLUser that that is ridiculous. ESPECIALLY BEFORE SENSITIVITIES BACK.

Now I'm in a very litigious area in a big city, and many attendings presumably do exactly what you are saying... .calling consults to "diffuse the situation".

I just feel strongly that's not what's best for patient care. First, the more consults a patient has, the more potential contradictions they hear. I have found it's often the patients with 5 consults that are the most frustated! Second, this is a waste of resources, period. In any regard, to my knowledge, there is no evidence that calling more consults helps avoid litigation.

The 60 year old VIP well controlled type 2 diabetic on metformin who is doing well until post op day 6 when she gets septic from a leak after a LAR for dysplasia manifesting with hyperglycemia 250, new onset atrial fibrillation and fever who get stat cardiology, endocrine, and infection disease consultation is not good for patient care. Maybe an ICU consult, of course, while they are crashing and about to go the OR emergently, but after the patient is diverted, and resuscitated, are all these consults really appropriate? Do they really avoid litigation? And if they did, isn't there a better way?

That's what happens at my institution fyi. ESPECIALLY with the VIPs. lt's so bad that there are times when I feel the VIPs are paradoxically getting worse care because cardiology is ordering all sorta of tests which aren't needed and the patient leaves with a PICC line for an antibiotic which isn't indicated for a duration which is ridiciulous.

Is it really appropriate to order consults so they can check mundane cultures and labs daily? I mean, on my service, I still check these things with the same rigor and frequency no matter what consult is following. If the patient is my primary, they are my responsibliity. I know you allude to this at the end of your message.

Lastly, regarding the comment that ID is more up to date on duration and proper agents... I actually am not sure about that. You may not be up to date on the latest trends by experts and thinkers in the field about duration of antibiotics for surgical patients, but don't be so sure they are experts on say intra-abdominal infections. A lot of them don't even know what surgery you did. Of course, it depends on your facility and knowledge, etc.

 

[dilated]

Well, whether or not it's a good thing, you can rest assured within a few years after they start bundling the payments for "care episodes" and each consult comes out of your bottom line the consult shotgunning will stop overnight.

 

[europeman]

exactly.


and i think that's a good thing.

good point!

 

[SLUser11]

Lastly, regarding the comment that ID is more up to date on duration and proper agents... I actually am not sure about that.

I agree with you somewhat. I went to a pharm-sponsored dinner one time recently because it was at my favorite Wichita steakhouse (Hereford House, bone-in ribeye). It was an ID doc talking about intra-abdominal infections, and was attended mostly by medicine docs. It was pretty amusing, and I came away feeling that I'm probably the best guy to treat surgical infections 95+% of the time.

Still, with the knee-jerk fashion that I've seen some surgeons order Zosyn, it reminds me of one of my go-to medical jokes:

What's the difference between a monkey and a surgical resident?

A monkey can name 2 antibiotics.

 

[GreatSaphenous]

Well, whether or not it's a good thing, you can rest assured within a few years after they start bundling the payments for "care episodes" and each consult comes out of your bottom line the consult shotgunning will stop overnight.

When do I consult ID? When the pt has severe immunosupression from HIV and ID is already seeing him and prescribing his cocktail. Otherwise nada. At my hospital, ID seems to be the biggest waster of medical resources. I really try to avoid the "load the boat" philosophy of medicolegal safety.

Infection management is not that complicated. We see the same 10-20 infectious organisms over and over and the number of antibiotics available is finite (especially when you limit yourself to your hospital's formulary). As for duration of therapy, do what ID does and pick last week's football score.

Just start broad spectrum, treat surgically when indicated, and reduce your antibiotics based on culture sensitivities. Oh, and keep your patients free from parasites (especially those with medical degrees).

 

[europeman]

When do I consult ID? When the pt has severe immunosupression from HIV and ID is already seeing him and prescribing his cocktail. Otherwise nada. At my hospital, ID seems to be the biggest waster of medical resources. I really try to avoid the "load the boat" philosophy of medicolegal safety.

Infection management is not that complicated. We see the same 10-20 infectious organisms over and over and the number of antibiotics available is finite (especially when you limit yourself to your hospital's formulary). As for duration of therapy, do what ID does and pick last week's football score.

Just start broad spectrum, treat surgically when indicated, and reduce your antibiotics based on culture sensitivities. Oh, and keep your patients free from parasites (especially those with medical degrees).

This is greatest post ever.

Well said!

 

[Quinn1988]

No, that sounds pretty unusual. We normally reserve ID consults for complicated patients or patients needing restricted Abx. Routine things and common post op infections don't get ID consults unless there are true indications for it (i.e. MDR, not improving despite appropriate regimen, allergies to every drug class, etc.).

Why would being allergic to every/most drug classes be ground for an ID consult? Are you just speaking in terms of antibiotics only?

 

[Smurfette]

Why would being allergic to every/most drug classes be ground for an ID consult? Are you just speaking in terms of antibiotics only?

I meant most antibiotic drug classes. These patients are complicated patients when they get an infection because you can't treat them with typical agents.

Sometimes you can't figure out what antibiotics to give them due to their allergies, and you need to give them something "restricted", unusual or with an 'off-label' indication, or have them get desensitized (not a common scenario, but I've seen it). In these cases, having ID help determine proper antibiotic therapy is extremely helpful and can prevent the patient from being inadequately treated (and hence, get sicker).

 

[Quinn1988]

I meant most antibiotic drug classes. These patients are complicated patients when they get an infection because you can't treat them with typical agents.

Sometimes you can't figure out what antibiotics to give them due to their allergies, and you need to give them something "restricted", unusual or with an 'off-label' indication, or have them get desensitized (not a common scenario, but I've seen it). In these cases, having ID help determine proper antibiotic therapy is extremely helpful and can prevent the patient from being inadequately treated (and hence, get sicker).

Ok I think I see what you are saying. Is it really possible to be desensitized to something one is allergic to? Does this also happen to be the same as an Allergy Study/Test?

 

[dpmd]

Not sure if the technique is similar for drug allergies, but with allergy shots they give you small but increasing quantities of the pollen and whatnot you are allergic to as a subcutaneous injection. Over time you, hopefully, quit responding the same way to it. That is done over years, which obviously wouldn't be helpful for someone with an infection and a drug allergy.

 

[Smurfette]

Not sure if the technique is similar for drug allergies, but with allergy shots they give you small but increasing quantities of the pollen and whatnot you are allergic to as a subcutaneous injection. Over time you, hopefully, quit responding the same way to it. That is done over years, which obviously wouldn't be helpful for someone with an infection and a drug allergy.

IIRC, the patient I remember best was monitored in the ICU and was given the Abx (PCN) that they were allergic to in incrementally larger doses with time (I can't remember how they spaced this), until they were able to tolerate the full dose needed. The patient was actually anaphylactic to PCN, so this was quite a production and getting the family to agree to it took a lot of effort on the part of the ID service. It did work though. Ultimately, the patient needed 6-8 weeks of IV antibiotics after finally getting negative cultures.

 

[Quinn1988]

IIRC, the patient I remember best was monitored in the ICU and was given the Abx (PCN) that they were allergic to in incrementally larger doses with time (I can't remember how they spaced this), until they were able to tolerate the full dose needed. The patient was actually anaphylactic to PCN, so this was quite a production and getting the family to agree to it took a lot of effort on the part of the ID service. It did work though. Ultimately, the patient needed 6-8 weeks of IV antibiotics after finally getting negative cultures.

Funny you mention that because PCN has the same effect on me as well. PCN isn't the only Abx I'm allergic to....As a result, seriously considering requesting an Allergy Test. Assuming I go this route, how exactly will that process work? I know it seems extreme, but will medical staff be ready to Intubate if the situation arises?

I know off topic, how the hell can one be intubated when their throats are swollen shut?(Aside from using NPA, Chest Tubes and going through the trachya(Sp?)

 

[SouthernSurgeon]

Funny you mention that because PCN has the same effect on me as well. PCN isn't the only Abx I'm allergic to....As a result, seriously considering requesting an Allergy Test. Assuming I go this route, how exactly will that process work? I know it seems extreme, but will medical staff be ready to Intubate if the situation arises?

I know off topic, how the hell can one be intubated when their throats are swollen shut?(Aside from using NPA, Chest Tubes and going through the trachya(Sp?)

Yes this is how it works. You gradually build up the dose from a very very small one to a therapeutic one, under continuous monitoring...if there are any signs of anaphylaxis you stop the desensitization and aggressively treat the allergic reaction.

Desensitization if usually reserved for rare cases where there are NO other good treatment options. The other thing about desensitization is that it is not a permanent process...if a person misses even one or two doses after undergoing desensitization they can develop a reaction again.