Summary
While trained infectious diseases (ID) specialists are regularly involved in inpatient
and outpatient care in the United States and Canada, these specialized services are
only rarely established in Germany. This article aims to summarize the findings of
numerous studies that investigated the impact of ID consultation services on patient
care and outcome in patients suffering from infectious diseases.
The strongest evidence for a clinical benefit is found in the context of Staphylococcus aureus bacteremia (SAB), where in-hospital- and day-30 mortality was significantly and consistently
reduced by about 40% in patients that were evaluated and treated in cooperation with
an ID physician. Furthermore, studies revealed that this effect was associated with
an improved adherence to standards of care. Newer studies show a reduced length of
hospital stay due to ID consultations, especially if patients are evaluated early
in the course of their hospital stay. Of note, informal or curbside consultations
do not seem to be equivalent to a formal ID consultation with bedside patient evaluation.
Studies in other patient groups (solid organ transplant recipients or intensive care
unit patients) or in the context of other infections (infective endocarditis, pneumonia,
other bloodstream infections) also revealed positive effects of ID consultations.
Higher rates of appropriate empirical and targeted antimicrobial treatments and de-escalation
strategies due to successful pathogen identification were documented. These modifications
resulted in lower treatment costs and decreased antimicrobial resistance development.
Although there are methodological limitations in single studies, we consider the consistent
and reproducible positive effects of ID consultations shown in studies in different
countries and health care systems as convincing evidence for the improved quality
of care and treatment outcomes in patients with infectious diseases. Thus, strong
consideration should be given to establish ID consultation services in small and medium
sized hospitals as well.
Zusammenfassung
Während in Nordamerika die Mitbetreuung stationärer Infektionspatienten durch klinische
Infektiologen in Form einer Konsiliararzt-Tätigkeit regelhaft erfolgt, ist eine derartige
Versorgung in Deutschland erst in wenigen Zentren etabliert. Diese Übersichtsarbeit
fasst die Ergebnisse der inzwischen zahlreich publizierten Studien zu den Effekten
eines infektiologischen Konsiliardienstes auf die Versorgung von Patienten mit Infektionskrankheiten
zusammen.
Die meisten und evidenzstärksten Daten liegen hierzu im Kontext der Staphylococcus aureus-Blutstrominfektion (SAB) vor. Übereinstimmend fand sich in Studien aus verschiedenen
Ländern ein klinischer Benefit für SAB-Patienten. Es zeigte sich ein signifikanter
Überlebensvorteil der vom infektiologischen Konsiliardienst mitbetreuten und mitbehandelten
Patienten – die Krankenhaus- und Tag-30-Sterblichkeit konnte um ca. 40% gesenkt werden.
Die Studien zeigen zudem, dass die Effekte mit einer vermehrten Einhaltung diagnostischer
und therapeutischer Qualitätsstandards verknüpft sind. Neuere Studien weisen zudem
auf eine kürzere Krankenhausaufenthaltsdauer hin, insbesondere wenn Patienten in der
frühen Phase des stationären Aufenthalts konsiliarisch gesehen werden. Eine rein telefonische
oder schriftliche Beratung erscheint einem formalen Konsil mit Evaluation der Patienten
am Krankenbett unterlegen.
Auch in anderen Patientengruppen (Organtransplantierte, Intensivstation-Patienten)
bzw. bei anderen Infektionen (Endokarditis, Pneumonie, andere Blutstrominfektionen)
konnten positive Effekte des infektiologischen Konsiliardienstes dokumentiert werden.
So kam es häufiger zu adäquater empirischer Antibiotika-Therapie und aufgrund erfolgreicher
Erregersicherung zu einer gezielten Anpassung und Deeskalation der Antibiotika. Damit
einhergehend waren geringere Antibiotika-Kosten zu verzeichnen, zudem wirkt sich die
gezielte Antibiotika-Strategie langfristig auch positiv auf die Resistenzentwicklung
aus.
Auch unter Berücksichtigung der methodischen Limitationen einiger Studien erscheint
überzeugend nachgewiesen, dass die konsiliarärztliche Tätigkeit durch klinische Infektiologen
zu einer verbesserten Versorgung von Patienten mit Infektionskrankheiten führt. Es
ist zu prüfen, ob auch kleinere und mittelgroße Kliniken in Deutschland standardmäßig
mit klinisch-infektiologisch ausgebildeten Ärzten ausgestattet werden sollen.
Schlüsselwörter
Keywords
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Article info
Publication history
Accepted:
September 3,
2015
Received in revised form:
September 3,
2015
Received:
June 26,
2015
Identification
Copyright
© 2015 Published by Elsevier Inc.
