Interaction between Clinical Microbiologists and Infectious Disease Specialists - possible obstacles Jos WM van der Meer MD PhD FRCP FRCP(Edin) Professor of Medicine Radboud University Nijmegen Medical Centre Nijmegen NL The profile of the ideal ID specialist • well-trained clinician – internal medicine – pediatrics – ...? • Subspeciality training – clinical ID – practical course in microbiology – epidemiology / public health /hygiene – research training The profile of the ideal clinical microbiologist • Well-trained physician • Speciality training – Laboratory skills (microbiology, molecular biology) – Practical training in clinical ID – Epidemiology / public health – Hygiene – Research training – Communication The competences within the ideal partnership ID-CM (1) Clinical ID Medical microbiology • Diagnosis of ID • Diagnosis of ID – Differential – Differential diagnosis diagnosis – Assessment of the – Assessment of the adverseries adverseries • causative • causative organism organism • state of host • state of host defense defense – Composition of a – Composition of a pathophysiological pathophysiological concept concept The competences within the ideal partnership ID-CM (2) Clinical ID Clinical Microbiology • Therapy • Therapy – Interpretation MIC – Interpretation MIC – PK/PD concepts – PK/PD concepts - Antimicrobial policy - Antimicrobial policy and prescribing and advice - Supportive care - Supportive care • Prevention • Prevention – Hygiene – Hygiene – Vaccination – Vaccination Encounter clinical ID & clinical M 20th century models (1) • medical microbiologists in the lab; clinicians take care of patients; consultation minimal. • medical microbiologists in the lab; clinicians take care of patients; consultation by telephone/notes. Encounter clinical ID & clinical M 20th century models (2) • medical microbiologists come out of the lab and advise clinicians. • medical microbiologists in the lab; infectious disease specialists advise other clinicians. Encounter clinical ID & clinical M 20th century models (3) • medical microbiologists run the lab, come out of the lab and synergise with ID clinicians and other clinicians. Encounter clinical ID & clinical M 21th century model • Optimal synergy in hospital between – the ID specialist – the medical microbiologist – the hospital hygiene service The infectious disease service line [Tompkins] Encounter clinical ID & clinical M 21th century model • Optimal synergy outside hospital between – the ID specialist – the medical microbiologist – GP’s (antimicrobial R/) – public health physicians – authorities Case history # 1 Male 40y • ER with arthritis L knee • ‘flu’ since 1 week (NSAIDS no effect), pain in knee since 1 day • Orthopedic surgeon: drainage (12h) Microbiologist: flucloxacillin + genta • Pain not responsive to morphin • 24h later: shock -> ICU • ID physician: History: chills !2d Phys ex/ pain, redness, blisters D/necrotising fasciitis Advice: surgery,+/clindamycin, IgG Case history # 2 Female 53y • Short bowel and TPN since 2004 • 3 wks fever (19 BC no growth) • Atrial thrombus; CVC not removable • R/Cefotaxim response? • Eosinophilic response • Pulmonary lesions (septic PE) ID/CM interaction: Case history # 2 Female 53y • Short bowel and TPN since 2004 • 3 wks fever (19 BC no growth) • Atrial thrombus; CVC not removable • R/Cefotaxim response? • Eosinophilic response • Pulmonary lesions (septic PE) ID/CM interaction: special cultures and prolonged incubation. Malassezia furfur and Rodotorula rubra Case history # 3 Female 67y • Bilateral neuropathy of peroneus nerve • CT scan: brain tumor • Brain biopsy: eosinophilic infiltrate; parasite? • Parasitologist: worm egg -> schistosomiasis? • Faecal exam: Schistosoma mansoni Case histories #1: Bedside examination pays off #2: Communication pays off #3: Microbiological expertise pays off Daily concerns • Internists think about treatment • Surgeons know only one antibiotic • Intensivists just give carbepenem • Oncologists treat infection like cancer • Hematologists just combine everything (never stop) New challenges • Increasing antimicrobial resistance • Stagnant development of antibiotics • Poor quality of antimicrobial prescribing • Poor compliance with hospital hygiene • Revolution in microbiology • Increasing numbers of immuno- compromised and frail patients • Advent of immunotherapy of infection New challenges in ID ID CM Emerging & re-emerging pathogens + + Stagnant development of antibiotics + + Quality of antimicrobial prescribing + + Compliance with hospital hygiene + + Revolution in microbiology + ++ Immuno-compromised & frail patients + + Advent of immunotherapy of infection ++ + Obstacles • Competence • Ego and other psychology • Finances • Time • Organisational constraints • Defensive medicine You really should You know it well consult the enough yourself!!! microbiologist! Bad dreams for the ID service • The medical microbiologist as an extinct species: only PhD’s run the laboratory • The microbiology laboratory outside the hospital Obstacles in physicians Changing physician behavior is considered by many to be an exercise in futility - an unattainable goal intended only to produce premature aging in those seeking the change. The more optimistic might describe the process as uniquely challenging. Sbarbaro Clin Infect Dis 2001:33 S240-4 .