By Carol A. Kemper, MD, FIDSA
ID: An Arbiter of Death?
SOURCE: Smith AGC, Yarrington ME, Baker AW, et al. Beyond infection: Mortality and end-of-life care associated with infectious disease consultation in an academic health system. Clin Infect Dis 2024; Jun 13:ciae325. doi: 10/1093/cid/ciae325. [Online ahead of print].
ID consultants see the sickest and most complicated patients in the hospital and are increasingly central to decisions made about code status and end-of-life treatment. Not only are we often the first to recognize a hopeless or incurable condition or infection, but a common request is to provide assurance to the team and the family that “nothing more can be done” for a dying patient. While I feel comfortable having those conversations, they often occur the first day I am meeting the patient and family, making me not just the specialist providing expert assessment but the arbiter of care and grief counselor all in one. Further, these conversations often are the most challenging and time-consuming (especially when meeting a disenchanted, angry, or dysfunctional family).
I am old enough to have garnered a great deal of experience with death and dying during the worst of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in the 1990s, and you learned that giving someone a good death was as important as providing care for them when alive. But my younger ID colleagues have not had that training or experience — and the experiential ladder now is slower. As hospitalists become busier and busier and more interested in a virtual experience, I find this duty is more often pushed on to me and my ID colleagues.
This retrospective review assessed the ID consulting experience during a 10-year period at a major academic hospital and two affiliated community hospitals in the United States from 2014 to 2023. Consult activity was classified by the location and the ID service line — at Duke University Hospital, there is both a general ID consulting service and a transplant ID service (the latter sees all consults for active leukemia/lymphoma patients, solid tumor or stem cell transplant patients, and those requiring ventricular assist devices). There also is a separate community ID service for the two affiliated hospitals.
During this 10-year period of time, there was a total of 60,820 ID consults provided for 37,848 individual patients. The number of ID consults increased during the study period, not accounted for by a change in bed numbers, from a rate of 5.0 to 9.9 consults per 100 inpatients (P < 0.001). In total, 7.5% of patients died during their hospitalization and 2.6% were discharged to hospice. Of these, 5.5% of patients on the community ID service died compared with 7.8% for general ID and 10.7% for transplant ID patients. Of the remainder, 67% were discharged to home and 18.2% to skilled nursing, long-term care, or rehab. Impressively, 43% of patients receiving ID consultation were rehospitalized within one year. Thirty-day mortality for patients receiving ID consultation was 9.3% for community ID patients, 10.2% for general ID, and 10.9% for transplant ID. The 180-day mortality for patients receiving ID consultation was 19% for community ID and 20.9% for general ID, while the 180-day mortality rate for those requiring both ID and nephrology consultation was 28.5%.
Palliative care consults were obtained in 7.6% of those also being seen by ID. The majority of palliative care consults occurred following the ID consult (69.5%), with a median time between the two of three days. Do not resuscitate (DNR) orders were placed in 16.3% of those consulted on by ID, and about half of those orders (52%) were placed any time after the ID consult and 12.2% were placed the day of the ID consult. Forty percent of those with DNR orders died during their hospitalization vs. 1.1% of those without DNR orders.
This article confirms that ID consults are being obtained significantly more often. ID is increasingly consulted for critically ill and complex patients with an approximately 7% to 10% chance of in-hospital mortality and a significant chance of death in the next 180 days. Recognizing and managing end-of life care is challenging, time-consuming, and sometimes stressful and sad. ID physician training should take this into account — how to recognize a dying patient requires experience; how to communicate this to a family requires even more. Giving patients a good death is a significant part of our job.
Preventing Recurrent UTI with Probiotics
SOURCE: Gupta V, Mastromarino P, Garg R. Effectiveness of prophylactic oral and/or vaginal probiotic supplementation in the prevention of recurrent urinary tract infections: A randomized, double-blind, placebo-controlled trial. Clin Infect Dis 2024;78:1154-1161.
About half of women experience urinary tract infection (UTI) during their lifetime, and around 20% to 25% will experience recurrent UTI (defined as three or more UTIs in a 12-month period or two UTIs in a six-month period). Those with two UTIs in a six-month period have a 50% chance of a third UTI. Repeated courses of antibacterials distort both intestinal and vaginal flora, further increasing the risk of urinary infection.
This double-blind, placebo-controlled study examined the risk of recurrent UTI in 174 premenopausal women with a history of recurrent UTI who received oral and/or vaginal probiotics. The women were randomized to four treatment groups: oral and vaginal placebo (group P), oral probiotics with vaginal placebo (group O), oral placebo and vaginal probiotic (group V), and both oral and vaginal probiotics (group OV). The products were used for eight days every month for four months. Oral probiotics consisted of oral lactic acid and bifidobacteria (Visbiome and Florimax; one capsule each daily), and the vaginal probiotic was Lactobacillus (either FloraBalance or EvaNew; one capsule daily). Clinical UTI was defined by symptoms, whereas microbiological UTI was based on a culture with ≥ 105 colony forming units of a single pathogen. Patients were seen monthly for six months with clinical and microbiological assessment (both urine culture and vaginal smear), and then were phoned monthly for six months to assess symptoms. Those who were symptomatic were seen in person.
The risk of UTI at the end of four and 12 months was significantly different among the four groups. At four months, the incidence of UTI for groups P, O, V, and OV, respectively, was 70.4%, 61.3%, 40.9%, and 31.8%. At four months, the risk of UTI in each of the intervention groups was lower than group P, and the risk of UTI in groups V and OV was significantly lower than in groups P and O (P < 0.05). In addition, the time to first symptomatic UTI for each of the four groups (P, O, V, and OV), respectively, was 69, 72, 124, and 142 days (P < 0.001). At 12 months, the incidence of UTI for groups P, O, V, and OV, respectively, was 95.5%, 77.3%, 61.4%, and 54.5%. Vaginal Lactobacillus colony counts were significantly higher in the OV group than in the other groups (P = 0.008). Further, within groups analysis at four months showed significant reductions in vaginal Escherichia coli colony counts in the V and OV groups compared with the other two groups.
These data indicate that a relatively simple, well-tolerated intervention with either vaginal probiotic or oral and vaginal probiotic, used for eight days every month for four months, significantly improved vaginal flora and reduced the frequency of recurrent UTI. The infection-free duration more than doubled in those using both oral and vaginal probiotic compared to those using none. By 12 months, the risk of recurrent UTI in those using both oral and vaginal probiotic was nearly halved compared with those using oral/vaginal placebos.
Treatment of recurrent UTI in women often feels like you are spinning your wheels, with little to offer except repeated courses of antibiotics. Anything that limits the frequency or time to recurrence is welcome. Similar studies in post-menopausal women are needed.
Carol A. Kemper, MD, FIDSA, is Medical Director, Infection Prevention, El Camino Hospital, Palo Alto Medical Foundation.
