International Journal of Infectious Diseases (2006) 10, 6165
Results: The departments most frequently requesting the consultation services of the
already been initiated in the great majority of patients (67.1%) before the consulta-Introduction
The role of infectious disease (ID) specialists hasrecently changed in both community and university
tion request. While the current therapy was changed in 57.4% of these patients,antibiotics were not necessary for 9.8%.Conclusions: Since the most common diagnoses were respiratory and urinary tract orbone and joint prosthesis infections, the ID specialists should have detailed knowledgeof these problems. Usage of antibiotics without ID consultation was prevalent,therefore a continuous educational program is a necessity for healthcare workersin the hospital.# 2005 International Society for Infectious Diseases. Published by Elsevier Ltd. Allrights reserved.
* Corresponding author. Tel.: +90 232 412 43 04;fax: +90 232 278 59 54.
E-mail address: email@example.com (N. Yapar).
1201-9712/$32.00 # 2005 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.ijid.2005.03.008ID department were Orthopedics (29.6%), Neurology (18.5%), Cardiology (11.8%) andInternal Medicine (10.4%). The main reasons were for diagnosis of unexplained fever(42.3%) and for antibiotic modification according to culture results (18%). Diagnosesmade by the ID consultant were pneumonia (16.7%), urinary tract infections (9.3%),bone and joint prosthesis infections (9.1%) and in 15.7% of the investigated patients,no infectious focus was determined. It was recognized that the use of antibiotics hadInfectious disease consultations and antibioticusage in a Turkish university hospital
Nur Yapar *, Mine Erdenizmenli, Vildan Avkan Oguz,Ziya Kuruuzum, Suheyla Serin Senger, Nedim Cakr, Ayse Yuce
Dokuz Eylul University School of Medicine, Department of Infectious Diseases and Clinical Microbiology,35340 Inciralt, Izmir, Turkey
Received 27 August 2004; received in revised form 20 November 2004; accepted 2 March 2005
Corresponding Editor: Michael Ellis, Al Ain, UAE
KEYWORDSInfectious diseases;Consultation;Antibiotic use
Objectives: The aim of this study was to investigate the various features of infectiousdisease (ID) consultations and the usage of antibiotics in a Turkish university hospital.Methods: A total of 395 consultation requests were recorded during a three-yearperiod.http://intl.elsevierhealth.com/journals/ijid
hospitals. In addition to the usual infectious diseases
antimicrobial therapies of these patients wereinitiated by ID specialists.
treatment were available in our hospital at the timeof study.
During the study period, a total of 395 consultationswere recorded; 121 of them were in the year 2000,142 were in 2001 and 132 were in 2002. One hundredand sixty-eight patients were female (42.5%) and227 were male (57.5%). The mean age of thepatients was 54.66 (SD: 19.29, range 1298).
The departments requesting most consultationswere Orthopedics (29.6%), Neurology (18.5%), Car-diology (11.8%) and Internal Medicine (10.4%).Departments referred to the ID service for consulta-tions are shown in Table 1. The most common pur-
62 N. Yapar et al.
Others 28 (7)A prospective study was designed to investigatethe features of ID consultations in our hospital. Thestudy period extended from 1 January 2000 to 31December 2002. All consultations were recorded ona form, and the name, age, sex, hospital ward,antibiotic use, purpose of consultation and diagnosisof the patient were included.
Appropriate antimicrobial therapy was defined asthe use of antibiotics that had in vitro activityagainst the infecting agents isolated or had clini-cally proven efficacy and that were given by anappropriate route and at adequate doses. Empiricantibiotic treatment was evaluated according to thepatients clinical condition, possible source of infec-tion, and place of acquisition. We were not able tocompare the antibiotics initiated before the con-sultation request with the recommendations of localguidelines, as no local guidelines for antibioticsuch as malaria, anthrax, brucellosis or HIV, inci-dences of nosocomial infections and infections ofthe immunocompromised patient have risen drama-tically. The number of infections caused by new, re-emerging or drug-resistant pathogens is growing dayby day, and the increased proportion of hospitalizedpatients with immunodeficiency has resulted in anincrease of severe and invasive infections.14 It hasbecome apparent during the past decades thatinclusion of an ID physician in the consultationprocess can favorably affect antibiotic usage andID specialists have more recently played a leadingrole in instituting programs of antibiotic control.5,6
In our hospital, up until 2003, there were no restric-tion policies and local guidelines for antibiotic pre-scription. In this study, we aimed to determine thepurposes of consultations and the usage of antibio-tics before and after ID consultation.
Dokuz Eylul University Hospital is a 750-bed tertiarycare university hospital in Izmir, Turkey. There hasbeen an Infectious Diseases and Clinical Microbiol-ogy Department here since 1997. This departmenthas an inpatient ward where the more usual infec-tions are treated but also supports the other hospi-tal wards as a consultation service. Four IDspecialists perform consultations and the sameteam tracks patient progress on a daily basis untiltermination of the infectious problem. IntensiveCare Unit (ICU) consultations were not includedin the study, because infections in the ICU arefollowed routinely; during the study period theTotal 395 (100)poses for consultation were for diagnosis ofunexplained fever (42.3%), antibiotic choice forbacterial pathogens identified in the patients cul-tures (18.0%), and diagnosis and treatment of prob-able bone and joint prosthesis (8.4%) or surgical siteinfections (8.1%). The most common diagnosesachieved by the ID consultants in the investigatedpatients were pneumonia (16.7%), urinary tractinfections (9.3%), infections of bone or joint pros-thesis (9.1%), and surgical site infections (8.9%)while there was no determined infectious focus in62 patients (15.7%). Of the cases diagnosed aspneumonia, 52 were nosocomial (13.2%) while theremainder were community-acquired cases (3.5%).When the relationship between the purpose of con-sultation and the diagnosis was considered it wasrecognized that the purpose and the final diagnosiswere similar in most of the patients. The mostcommon purposes of consultations and the diag-noses of these patients are shown in Tables 2 and 3.
It was recognized that microbiological cultures of289 patients had been performed (73.2%) prior to
Table 1 Departments referring to the Infectious Dis-eases service for consultation.
Departments n (%)
Orthopedics 117 (29.6)Neurology 73 (18.5)Cardiology 47 (11.8)Internal Medicine 41 (10.4)Neurosurgery 23 (5.8)Dermatology 18 (4.6)General Surgery 14 (3.5)Pulmonary Medicine 13 (3.4)Ear Nose Throat Surgery 12 (3)Cardiovascular Surgery 9 (2.4)
the consultations and empirical antibiotic therapyhad been initiated in 265 (67.1%) of the patients atthis time. The most commonly used antibiotics wereciprofloxacin (86 patients, 21.8% of all patients),ampicillinsulbactam (64 patients, 16.2%), glyco-peptides (46 patients,11.6%), third-generationcephalosporins (45 patients,11.4%), cefazolin (33
these antibiotics was unnecessary, and they were
medical care. An experienced ID specialist canoften decrease the use of expensive diagnostic
Infectious disease consultations and antibiotic usage 63
Table 2 Most common purposes of Infectious Diseasesservice consultations.
Purpose n (%)
Unexplained fever 167 (42.3)Antibiotic selection 71 (18.0)Prosthesis infection 33 (8.4)Surgical site infection 32 (8.1)Diarrhea 15 (3.8)Urinary tract infection 15 (3.8)CNSa infection 14 (3.5)Soft tissue infection 14 (3.5)Septic arthritis 7 (1.8)Osteomyelitis 6 (1.5)Febrile neutropenia 3 (0.8)a CNS, central nervous system.patients, 8.3%), carbapenems (30 patients, 7.6%)and aminoglycosides (30 patients, 7.6%). Antimicro-bial therapy was prescribed as monotherapy in 125of 265 (47.2%) patients and 140 (52.8%) patients hadcombined therapy with two or three drugs. Approxi-mately 51% of usage of the antibiotics initiatedbefore the consultation request was in surgicalwards and the remainder was in the medical wards.Antibiotics initiated before ID consultations werediscontinued in 26 patients (9.8%) since the use of
Table 3 Most common diagnoses after consultation.
Diagnoses n (%)
Pneumonia 66 (16.7)Urinary tract infection 37 (9.3)Infection of prosthesis 36 (9.1)Surgical site infection 35 (8.9)Cellulitis 20 (5)
Osteomyelitis 19 (4.8)CNSa infection 15 (3.8)Diabetic foot infection 12 (3)Infective endocarditis 11 (2.8)Gastroenteritis 8 (2)Septic arthritis 7 (1.8)Sepsis 6 (1.5)Catheter infection 5 (1.3)Intra-abdominal infection 4 (1)Bacteremia 4 (1)Neutropenic fever 3 (0.8)Fungemia 2 (0.5)No infection 62 (15.7)Others 43 (11)a CNS, central nervous system.tests, use outpatient antibiotic treatment andswitch intravenous therapy to appropriate oralagents as early as possible.57 Consultation by anID practitioner for the care of bacteremia was foundto reduce morbidity and mortality as well as reducethe total cost of care.6,8
In our country, Infectious Diseases and ClinicalMicrobiology is a specialty and Infectious Diseasesand Clinical Microbiology specialists follow patientswith traditional infections such as brucellosis,typhoid fever, malaria, and anthrax and have theirown clinical microbiology laboratories. Additionally,ID specialists manage the in