Editorial Commentary: Telephone Consultation for Staphylococcus aureus Bacteremia: Opening Pandora's Box

Abstract

An unsolicited call from a physician seeking advice about the management of a complicated condition such as Staphylococcus aureus bacteremia (SAB) is sometimes analogous to opening Pandora’s box. As soon as the conversation begins, troubles related to incorrect information, misstated facts and other misunderstandings figuratively “fly out.” Too often such discussions include preliminary, second-hand, incomplete or incorrect information. Surprisingly, the impact of telephone consultations on patient outcomes has received little scientific scrutiny. The study by Forsblom et al in this issue of Clinical Infectious Diseases is an important attempt to remedy this gap [1]. Forsblom et al retrospectively compared the relative effectiveness of bedside consultation with informal (mostly telephone) consultation for patients with SAB. Bedside infectious disease (ID) consultation was associated with more radiologic imaging, more frequent identification of focal infections, and longer hospitalization. However, bedside ID consultation had a crucially important benefit: it was associated with a lower 90-day mortality than telephone consultation. A sufficient duration of antibiotic therapy was given to 85% of patients who received a bedside consultation, compared with 63% of patients who were managed with telephone consultation (P = .008) in this study. Similar results were described in another study by Lahey et al [2]. In contrast, Fowler et al found that duration of antibiotic use was not significantly different in patients treated with or without formal ID consultation [3]. However, all physicians caring for patients with SAB received initial management recommendations by telephone and were given the option of formal bedside consultation. Only patients for whom recommendations were followed had significantly fewer relapses (6.3% vs 18.2%; P < .01) and a nonsignificantly lower rate of death [3]. These findings lead us to 2 general conclusions: first, assigning the proper duration of antibiotics is necessary but not sufficient to produce better outcomes in SAB; and second, clinicians do not always follow advice that is given by telephone or even by bedside consultation. Antibiotic selection is also a problem when patients with SAB are managed by means of telephone consultation in locations where methicillin-resistance and reduced susceptibility to vancomycin are prevalent among S. aureus isolates. For example, Kaye et al found that a majority of patients with SAB cared for in community hospitals in the southeastern United States did not receive an appropriate effective antibiotic as initial therapy [4]. As all ID specialists well know, antibiotic choice and duration are only part of the solution when treating SAB. Identification and eradication of primary or metastatic foci of SAB are essential components of the proper management of SAB. Failure to detect complications such as endocarditis, abscesses, or osteomyelitis has a deleterious impact on the chance of relapse and survival in patients with SAB [2, 3]. Identification of these complications requires knowing what to ask (the patient), where to look (physical examination), and how to find or prove the existence of these focal or metastatic infections. ID specialists who are asked to provide telephone consultations must rely on another clinician’s primary observations. If the physician asking for telephone advice does not provide accurate or thorough information, important diagnoses such as vertebral osteomyelitis can be missed. Indeed, Forsblom et al found that metastatic complications and focal infections were detected in a significantly higher percentage of patients with SAB who had bedside consultation, an observation that was also seen in the study by Lahey et al [2]. Varying amounts of relevant clinical information necessary for the proper Received 21 September 2012; accepted 24 July 2012. Correspondence: Dr. Vivian H. Chu, MD, Duke University Medical Center, Box 102359, Durham, NC (vivian.chu@duke. edu). Clinical Infectious Diseases © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/cid/cis895