Controlling Antibiotic Use 211

clear antibiotic prescribing guidelines is a moot point. Furthermore, the authors do not mention the availability or role of a microbiology, infection control or clinical pharmacy service in any of the seven hospitals surveyed. All these services are likely to have some impact on improving prescribing. Despite these obvious limitations, this study adds further weight to the potential beneficial impact of an active ID service on antibiotic prescribing. Similarly, a recent comparative prospective study ex- amined the impact of an ID consult on the clinical efficacy of antibiotic t reatment in a Spanish general hospital. 25 They showed that the clinical value of microbiological information is significantly enhanced when it is con- sidered together with information provided by a specialist in infectious diseases. For example, the group with an ID specialist had significantly less inappropriate initial t reatment with antibiotic (34% vs. 45%; P<O.05) and amendments of inappropriate t reatment in light of the microbiological results were also significantly more fre- quent (57.6% vs. 33.3%; P<0.025). Furthermore, less patients in the ID specialist group had persistence of infection (27% vs. 12%). In our own study 2j examining the impact of an infection consultation service for bac- teraemia on the use of resources we found that the median daily cost of antibiotics were lowered in patients even when complying with the sepsis policy, but overall the impact was of redistribution of resources rather than cost reduction. The latter is an important message to those preoccupied with purely cutting costs.

There has been a longstanding debate that specialists will contribute excessively to the cost of care. 3° ID phys- icians are particularly vulnerable to this in that they often look after patients who are the 'sickest' or who are the complicated end of the spectrum of infection and who often have expensive underlying diseases such as AIDS. Indeed, an excellent study from the U.S. by Classen & colleagues 3~ compared 806 hospitalized patients who were seen by an infectious disease consultant with 496 patients matched for severity of illness, who were not seen by ID physicians. This study revealed an interesting paradox: overall, an ID consult was associated with greater length of mean hospital stay (14.7 days vs. 8.97 days for controls), greater number of antibiotic choices (2.7 vs. 1.26), higher mean duration (10.69 vs. 4.4 days) and mean cost ($1448 vs. $446) of antibiotics prescribed. If the consult, however, was performed in the last third of the hospital admission then there was an opposite trend: shorter length of hospital stay and lower antibiotic costs than controls. The authors can give no satisfactory explanation for this paradox, except to suggest that an ID consult in the latter part of hospital admission may have stimulated an earlier hospital discharge, possibly

through use of a home/communi ty IV therapy pro- gramme. In the age of evidence-based practice, this study clearly highlights the need for well controlled studies to analyse the impact of all aspects of an ID service. The collection and analysis of these data is going to be indispensible if we are going to show key decision makers that ID physicians are not expensive, that their in- terventions provide better outcome for patients with sepsis, improve the quality of care and above all are worth investing in. Finally, if rational prescribing of antibiotics is to be achieved, all those interested in in- fection should work as a multi-disciplinary team in close collaboration with non-specialists and hospital managers. These lessons should apply to prescribing of anti- microbials in the community.

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