Response to Tande et al.’s Publication: “Association of a Remotely Offered Infectious Diseases eConsult Service With Improved Clinical Outcomes”

Dear Editor,

We commend Tande et al. [1] on establishing an infectious diseases (ID) e-consultation service that showed an improvement in outcomes. We were particularly interested in the significant reduction in 30-day mortality and processes of care in patients who received ID e-consultation.

We would like to share our experience of our ID consultation service in Al Mafraq Hospital, Abu Dhabi, United Arab Emirates. Al Mafraq Hospital is a 400-bed government teaching hospital with a single ID physician. It is a government hospital that has recently moved to a new hospital site run by the Mayo Clinic, now known as Sheikh Shakbout Medical City. We established an ID consultation service in July 2019. On average, 160–200 consults are completed per month, and 80% of the consultations are in person, whereas the rest are e-consultations. Our consultation service differs in the fact that in addition to solicited consultations, we also have a proactive consult service based on significant microbiology results (positive cultures from sterile sites) and patients started on restricted antibiotics. All solicited and unsolicited consultations are seen within 24 hours.

An evaluation of all our ID consultations during the month of July 2019 was carried out in September 2019 and showed results similar to those of Tande et al. A total of 124 patients were seen (average age, 54 years). Sixty-seven (54%) of the ID consults were solicited consultations, whereas 57 (46%) were generated from either significant positive microbiology results or restricted antibiotics. Forty (70%) of the 57 unsolicited consultations were generated from significant microbiology results, and 17 (30%) from prescription of restricted antibiotics. Ninety-four (76%) ID consults were provided to medical specialities, and the remaining 30 (24%) to surgical specialities. Forty (31%) of the patients seen had a bacteraemia. Our recommendations were followed in 114 (91%) of the ID consults. The 30-day mortality rate for patients seen in the ID consult service was 4% (5 patients), similar to that described in the study by Tande et al. [1]. Interestingly, we also found an impact on our antimicrobial stewardship program. Antibiotics were discontinued in 3 patients (2%). Broad-spectrum antibiotics were changed to narrow-spectrum antibiotics in 33 patients (27%). Carbapenems were changed to narrow-spectrum antibiotics in 7 patients (21%).

We agree with Tande et al. [1] that similar studies are needed with a focus on outcomes. These should be prospective and large-scale, involve different sites, and assess cost-effectiveness. We would also recommend an assessment of the impact on stewardship. We support the recommendation for hospitals to consider developing ID consultation services to improve stewardship and outcomes for patients with infection. This should include a combination of face-to-face consultations and e-consultation. We would also recommend extending solicited consultations to patients on restricted antibiotics and those with significant microbiology results. Such services can be provided across a network of hospitals in order to improve efficiency.