Editorial Response: Impact of Infectious Diseases Specialists

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Byl and associates have gathered some interesting data about the use of blood cultures in patient care [1]. Their detailed investigation of the therapy for and outcomes of bacteremia as well as the impact of infectious diseases specialists (IDSs) on the quality of both empirical and directed antimicrobial therapy provides useful insight into medical care. They chose to assess medical decision-making in the treatment of bacteremia at four critical stages: when the blood for culture was drawn, after the culture was reported positive, after the gram stain result was reported, and after the antibiotic susceptibility results were known. They used the outcomes indicators of mortality and compliance with established treatment guidelines. Their methodology and analyses are good, although the details of their antibiotic-use guidelines are not presented and might possibly be seen as self-serving by some of the other departments in their hospital in Belgium. The relationship of mortality rate to severity of illness and, independently, to appropriate empirical antibiotic therapy comes as no surprise. The benefits of correct antibiotic use in reducing mortality have been well documented, yet in most series investigators report selection of antibiotics for suspected bacteremia as appropriate for only two-thirds of patients [2‐5]. Although the finding of Byl et al. that appropriate empirical therapy was given to 63% of patients is consistent with those results, the failure of the empirical regimen to cover 68% of patients with fungemia and 46% of patients with nosocomial bacteremia is of concern. Notification of the physician that blood cultures are positive is clearly of value. In the study of Byl et al. [1] the blood culture and gram stain results increased the percentage of patients receiving appropriate therapy from 63% to 94%. The increase was also coincident with, although not simply due to, involvement of IDSs in patient care. This article shows the IDSs’ decisions regarding empirical antibiotic therapy to be significantly better than those of other physicians (P ¶ .001), especially for hospitalized patients and those who had recently received antimicrobial therapy (P 5 .0024). Such findings raise concerns about the patients who were not seen by an IDS and who still received inappropriate therapy even after the final susceptibility test results came back. The investigators also reviewed the overuse of broad