By: AMFS Infectious Disease Expert
Dealing with Infectious Disease
Infectious diseases are among the most common conditions for which patients seek medical care, and potentially the most serious. Fortunately, since the discovery of penicillin over 70 years ago, antibiotics have made the treatment of serious infections highly successful. Nevertheless, physicians and advanced practioners such as nurse practitioners and physician's assistants must use caution in administering antimicrobial medications, both to ensure effectiveness and to prevent side effects. Careful prescribing will help minimize the legal risks resulting from antibiotic treatment.
Diagnosis and Treatment
The first question to ask when addressing any presumed infectious illness should be "Is it an infection"? Many illnesses, such as systemic lupus erythematosis and sarcoidosis, mimic infection but do not benefit from antibiotics. The next question to ask would be "Should it be treated"? Certain conditions, such as chronic bronchitis and chronic cystitis in the elderly, are characterized by bacterial growth and low-grade inflammation, but without signs of systemic infection, treatment is often counterproductive.
When the decision is made to treat an infection, the treatment plan should be carefully explained to the patient and family, including benefits, risks and potential side effects. These should be documented in the chart. Potential reasons for treatment failure should be discussed with the patient and documented in the record as well. An adequate plan for follow-up should be instituted.
What are the potential medicolegal risks of treating infectious diseases? These reflect the issues found in other fields of medicine: failure to diagnose, delay in treatment, undertreatment, adverse effects of treatment, etc. Unfortunately, when dealing with infection, the potential for major disability or death is often present, and it often behooves a primary physician to consult with an Infectious Disease physician in difficult cases.
Failure to Diagnose
Failure to diagnose occurs in all areas of medicine despite major advances in diagnostics. A physician or advanced practitioner must take a thorough history to identify any special risks for infection, such as foreign travel, animal exposure, etc., and perform a thorough physical exam. Obtaining broad cultures, particularly of blood and urine, in critically ill patients is a routine part of hospital medicine. A spinal fluid examination should be performed if there is any concern for meningitis or encephalitis. Localized infections in the chest, abdomen or pelvis generally should have imaging by computerized tomography or ultrasound and aspiration for culture. All significant diagnostic considerations should be documented in the medical record, not least to indicate to a reviewer or attorney that a condition was considered, even if not ultimately treated.
Delay in Diagnosis or Treatment
Treatment delay is uncommon for infectious illnesses, as early treatment and even overtreatment tends to be the rule. Nevertheless, if life-threatening conditions such as sepsis or meningitis or limb-threatening conditions such as necrotizing fasciitis are significant considerations, treatment should be initiated right away, even before diagnostic tests are performed.
Undertreatment is also rare except with certain specific conditions such as endocarditis and osteomyelitis. Unfortunately, many otherwise excellent physicians are not familiar with treatment guidelines for these conditions or for infections with certain pathogens like Staphylococcus aureus. A relapse in such a case can have disastrous consequences. Guidelines are now increasingly available for treating of everything from ear infections to bloodstream infections to HIV. Physicians should be aware of guidelines from national medical groups like the Centers for Disease Control and Prevention (CDC) and the Infectious Disease Society of America (IDSA). While guidelines are neither perfect nor all-inclusive, they usually represent the consensus view of experts in the field, and a physician should deviate significantly from them only after careful deliberation. Reasons for not following guidelines, such as allergies or intolerance to a certain medication or patient refusal to coooperate with the treatment plan, should be thoroughly documented in the medical record.
Finally, adverse effects can jeopardize treatment success. Side effect profiles of antibiotics should be explored and explained to the patient and family, as well as documented in the chart. Serious drug interactions, such as that between rifampin and warfarin or between linezolid and serotonin reuptake inhibitors like fluoxetine, should be considered and avoided if possible.
Treating infectious diseases requires the same attention to detail as treating any other serious condition. A doctor or advanced practitioner must be thoughtful, thorough and knowledgeable of the medical literature and treatment recommendations. He or she must communicate effectively with the patient and patient's family. And, to repeat, document everything. Close attention to these points will go a long way toward maximizing success and minimizing the medicolegal risk for the practitioner.