Infectious disease services: a survey from four university hospitals in Germany

[Infectious Diseases - a new specialty for postgraduate training in Germany]

Medicine in Germany is currently facing major structural and economic challenges. Infectious Diseases, with the recent introduction of a new specialty in "Internal Medicine and Infectious Diseases" and with the existing additional training for almost all specializations, will make an important contribution to overcoming these challenges. Expertise in infectious diseases has to be very broad and requires high interdisciplinarity, which makes infectious diseases an attractive and demanding specialty. The complex fundamentals of infectious diseases must now be quickly conveyed to as many physicians as possible in a short period of time, as part of their specialization or as additional training. Until this is achieved, transitional solutions will be necessary for some time. The adaptation of the current billing and reimbursement system for infectious diseases services and improved intersectoral cooperation are of the utmost importance for the further development of the specialty.

Complexity of patients with or without infectious disease consultation in tertiary-care hospitals in Germany

PURPOSE

Patients seen by infectious disease (ID) specialists are more complex compared to patients treated by other subspecialities according to Tonelli et al. (2018). However, larger studies on the complexity of patients related to the involvement of ID consultation services are missing.

METHODS

Data of patients being treated in 2015 and 2019 in four different German university hospitals was retrospectively collected. Data were collected from the hospitals' software system and included whether the patients received an ID consultation as well as patient clinical complexity level (PCCL), case mix index (CMI) and length of stay (LOS) as a measurement for the patients' complexity. Furthermore, a comparison of patients with distinct infectious diseases treated with or without an ID consultation was initiated.

RESULTS

In total, 215.915 patients were included in the study, 3% (n = 6311) of those were seen by an ID consultant. Patients receiving ID consultations had a significantly (p < 0.05) higher PCCL (median 4 vs. 0), CMI (median 3,8 vs. 1,1) and deviation of the expected mean LOS (median 7 days vs. 0 days) than patients in the control group. No differences among hospitals or between years were observed. Comparing patients with distinct infectious diseases treated with or without an ID consultation, the differences were confirmed throughout the groups.

CONCLUSION

Patients receiving ID consultations are highly complex, frequently need further treatment after discharge and have a high economic impact. Thus, ID specialists should be clinically trained in a broad spectrum of diseases and treating these complex patients should be sufficiently remunerated.

Definition of patient complexity in adults: A narrative review

Background

Better identification of complex patients could help to improve their care. However, the definition of patient complexity itself is far from obvious. We conducted a narrative review to identify, describe, and synthesize the definitions of patient complexity used in the last 25 years.

Methods

We searched PubMed for articles published in English between January 1995 and September 2020, defining patient complexity. We extended the search to the references of the included articles. We assessed the domains presented in the definitions, and classified the definitions as based on (1) medical aspects (e.g., number of conditions) or (2) medical and/or non-medical aspects (e.g., socio-economic status). We assessed whether the definition was based on a tool (e.g., index) or conceptual model.

Results

Among 83 articles, there was marked heterogeneity in the patient complexity definitions. Domains contributing to complexity included health, demographics, behavior, socio-economic factors, healthcare system, medical decision-making, and environment. Patient complexity was defined according to medical aspects in 30 (36.1%) articles, and to medical and/or non-medical aspects in 53 (63.9%) articles. A tool was used in 36 (43.4%) articles, and a conceptual model in seven (8.4%) articles.

Conclusion

A consensus concerning the definition of patient complexity was lacking. Most definitions incorporated non-medical factors in the definition, underlining the importance of accounting not only for medical but also for non-medical aspects, as well as for their interrelationship.

Antimicrobial Stewardship with and without Infectious Diseases Specialist Services to Improve Quality-of-Care in Secondary and Tertiary Care Hospitals in Germany: Study Protocol of the ID ROLL OUT Study

BACKGROUND

Antimicrobial stewardship (AMS) programs aim to secure the rational prescription of antibiotics through implementing department- or hospital-level activities. Infectious disease (ID) specialists improve the quality of care and outcomes in infection patients predominantly by individual consultations and patient-level interventions. While hospital AMS programs are established to various extents in Germany, ID specialist services are rarely available in this country. In the ID ROLL OUT study, we will implement and evaluate hospital-level AMS tools with and without ID specialist services in secondary and tertiary care hospitals. We aim to identify means to comprehensively and sustainably improve the quality of care of patients with infectious diseases.

METHODS

This project is a clustered, two-armed intervention study, which will be conducted in ten secondary and tertiary (non-university) care hospitals in Germany. The intervention groups are stratified by key characteristics of the hospitals. We will compare two interventional strategies: implementation of AMS teams and implementation of AMS teams combined with the activities of ID specialists (AMS + IDS).

PLANNED OUTCOMES

The primary outcome is the quality of care as measured in changes in a Staphylococcus aureus bacteremia (SAB) score (as an indicator of difficult-to-treat infections) and a community-acquired pneumonia (CAP) score (as an indicator of common infections) compared to a baseline pre-interventional period. Our secondary outcomes comprise patient- and hospital-level outcomes, such as the quality and frequency of antibiotic treatment, in-hospital mortality, duration of hospitalization, and C. difficile incidence (associated diarrhea episodes). The study may provide urgently needed key information for the aspired advancement of ID care in Germany.

TRIAL REGISTRATION

DRKS00023710 (registered on 9th April 2021).

Establishment of an interdisciplinary board for bone and joint infections

PURPOSE

The incidence of bone and joint infections is increasing while their treatment remains a challenge. Although guidelines and recommendations exist, evidence is often lacking and treatment complicated by complex clinical presentations and therapeutic options. Interdisciplinary boards shown to improve management of other diseases, seem potentially helpful. We describe the establishment of an osteomyelitis board to show the existing demand for such a platform.

METHODS

All patients discussed in the board for bone and joint infections between October 2014 and September 2020 were included in this retrospective study. Data were extracted from patient records and analyzed descriptively.

RESULTS

A total of 851 requests related to 563 patients were discussed in the board during the study period. After a run-in period of 3 years, a stable number of cases (> 170/year) were discussed, submitted by nearly all hospital departments (22 of 25). Recommendations were mainly related to antibiotic treatment (43%) and to diagnostics (24%). Periprosthetic joint infections were the most frequent entity (33%), followed by native vertebral osteomyelitis and other osteomyelitis. In 3% of requests, suspected infection could be excluded, in 7% further diagnostics were recommended to confirm or rule out infection.

CONCLUSIONS

A multidisciplinary board for bone and joint infections was successfully established, potentially serving as a template for further boards. Recommendations were mainly related to antibiotic treatment and further diagnostics, highlighting the need for interdisciplinary discussion to individualize and optimize treatment plans based on guidelines. Further research in needed to evaluate impact on morbidity, mortality and costs.

[Organisational and staff requirements for antimicrobial stewardship activities in hospitals : Position paper of the Commission on Anti-Infectives, Resistance and Therapy (Commission ART) at the Robert Koch Institute, with advice from professional associations]

Increased awareness of the rising antimicrobial resistance problem and impending loss of suitable treatment options for infectious diseases have changed patient care. Antimicrobial/antibiotic stewardship (ABS) activities aiming to optimize antimicrobial treatment were specified in international (WHO, ECDC) and national programmes and evidence-based practice guidelines. In Germany, ABS in hospitals is enshrined in the Infection Protection Act §23 and in a national guideline. The position paper presents the goals and tasks of ABS as well as the necessary organisational and staff requirements.Qualified training and education, mandates and support from hospital directors, and the provision of sufficient resources are essential prerequisites for the successful work of the ABS team. The ABS team should work hospital-wide across clinical services. Their main tasks are developing and implementing an ABS programme tailored to local needs and the conditions of the hospital, taking into account anti-infective drug prescribing, the resistance situation and case mix. Their tasks also include drafting and implementing in-house recommendations for diagnosis, prophylaxis and treatment of important infectious diseases. The ABS team should be interdisciplinary and include specially qualified doctors and pharmacists. Doctors commissioned for ABS should support this team and take the department-specific concerns into account. The document specifies a minimum ABS staff of one full-time equivalent (FTE) per 500 beds. Depending on the case mix and specialties, additional staff may be required. It proposes that there should be 0.1 FTE doctors commissioned for ABS per 100 beds.

Epidemiology of candidemia and impact of infectious disease consultation on survival and care

BACKGROUND

The aim of this study was to analyse temporal changes in the epidemiology of candidemia assessing patient's characteristics, risk factors, diagnostic management, treatment, and outcome in a tertiary care hospital in South Eastern Germany.

METHODS

In this retrospective cohort study patients with blood cultures positive for Candida spp. were identified from the microbiological database in the years 2006-2018. A detailed collection of patients' characteristics was obtained for the time periods 2006-2008 and 2016-2018. Risk factors for survival were analysed in a logistic regression analysis.

RESULTS

In the years 2006-2018, a total of 465 episodes of candidemia were identified. An increase in candidemia cases was evident in the period of 2016-2018 compared to 2006-2015 and to 2006-2008 in absolute numbers and adjusted to patient-days. C. albicans was responsible for 62.8% of cases in 2006-2008 and 51.2% of all cases in the years 2016-2018, respectively, whereas there was a significant increase of C. glabrata in the latter period (16.3-31.5%). Overall mortality was not significantly different in the two periods. Infectious diseases consultation led to a lower mortality of patients with candidemia and to a higher adherence to guidelines. In multivariate analysis, only complete change or extraction of intravascular indwelling material and female gender were independent predictors for survival.

CONCLUSION

We observed an increase in candidemia rates and rates of non-albicans spp. over time. A complete change of all catheters and/or indwelling devices improved survival. ID consultation led to a better guideline adherence.

Practices, organisation, and regulatory aspects in advising on antibiotic prescription: the international ESCMID AntibioLegalMap survey

PURPOSE

Giving advice about antibiotic prescription through dedicated consultations is a cornerstone of antibiotic stewardship programmes. Our objective was to explore practices, organisation, and regulatory requirements related to antibiotic advising.

METHODS

We performed an international, exploratory, Internet-based, cross-sectional survey targeting infectious diseases and clinical microbiology specialists. It was disseminated through ESCMID and ESGAP networks.

RESULTS

Answers from 830 participants (74 countries, 77% of participants from Europe) were collected. Consultations were mostly given on demand (81%, 619/764), while unsolicited consultations targeting specific conditions (e.g., positive blood culture) were less frequent (66%, 501/764). Consultations usually included indications on diagnostic work-up and follow-up (> 79%). Curbside consultations (i.e., without examining the patient) were reported by 82% (598/733) of respondents, mainly by phone (89%, 531/598). The referring physician was considered authorised not to follow the advice by 57% (383/676). Direct consultations (i.e., after examining the patient) were recorded in the medical file more frequently than curbside consultations (69%, 472/689 vs 35%, 206/592). Concerning legal liability, the majority of respondents considered that it is shared between the adviser and the referring physician, who, however, is considered primarily responsible. The advisers' liability was considered to be lower in cases of curbside and unrecorded consultations. Significant inter-countries and intra-country variability were identified, suggesting that the setting markedly influenced practices.

CONCLUSION

Significant variability exists in the practice of antibiotic advising. This concerns both the organisation of care and how advisers perceive regulatory requirements. These elements must be taken into account when implementing antibiotic stewardship programmes and when training stewards.