REVIEW

CURRENT
OPINION The impact of infectious diseases consultation on
oncology practice
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Bruno P. Granwehr a and Dimitrios P. Kontoyiannis b

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Purpose of review
Traditional utilization of infectious diseases consultants by oncologists ranges from inpatient management of
a variety of acute infectious syndromes to management of ambulatory patients with acute or chronic
infections; however, there is a paucity of data to evaluate in which circumstances the impact of infectious
diseases input may be most valuable.
Recent findings
Data derived from the general population of patients emphasize the value of infectious diseases
consultation in specific infections, such as Staphylococcus aureus bacteremia, candidemia, and hepatitis C
virus infection. In addition, infectious diseases involvement has been associated with greater adherence to
guidelines (up to 34% increase), more appropriate antibiotic utilization (up to 52% increase in appropriate
duration), decreased cost and complications of care, and lower mortality (up to 17% decrease). Recent
studies suggest that bedside, formal infectious diseases consultation is more optimal than informal
interactions (e.g., e-mail, telephone, other). Furthermore, infectious diseases consultants play central roles in
antibiotic stewardship, infection control, and quality improvement, particularly in oncology centers.
Summary
Infectious diseases consultants contribute value in various inpatient and outpatient infections, decreasing
mortality, cost, and complications.
Keywords
adherence with recommendations, bacteremia, fungemia, formal infectious diseases consultation, informal in-
fectious diseases consultation

INTRODUCTION improve despite broad-spectrum antibiotics, assist-

Infectious diseases represent a complex array of
diseases displaying the delicate interplay of host
defense, environment, and continuously adapting
organisms. New organisms emerge and reemerge,
ranging from West Nile virus to HIV to tuberculosis.
In addition, the population is aging, with corre-
sponding increases in rates of chronic diseases and
cancer. In 2001 in Texas, 9% of patients admitted for
infection had underlying malignancy [1]. By 2025,
costs of infection in cancer patients over 65 years of
age are estimated to increase by as much as 45% [1].
Appropriate utilization of infectious diseases con-
sultation will play a key role in reducing the costs, as
well as complications, of infection in this aging and
increasingly complex population.
There is a paucity of data regarding the value of
infectious diseases consultation. Traditional areas in
which inpatient infectious diseases consultation is
sought include critically ill patients with fever of
unknown origin and persistent infections that fail to
ance in diagnosis, and antibiotic management in
patients with drug allergies, and modification or
change of highly active antiretroviral therapy
(HAART) for HIV [2]. The involvement of infectious
diseases in inpatient specialty areas has been dem-
onstrated, including orthopedic and ICUs [3,4]. In
an orthopedic service in Switzerland, infectious dis-
eases consultation resulted in modification of the
antibiotic regimen in 88% of cases, with 32.4%
a
Department of Infectious Diseases, Infection Control, and Employee
Health and bDivision of Internal Medicine, Department of Infectious
Diseases, University of Texas, M.D. Anderson Cancer Center, Houston,
Texas, USA
Correspondence to Bruno P. Granwehr, MD, MS, Department of Infec-
tious Diseases, Infection Control, and Employee Health, University of
Texas, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1460,
Houston, TX 77030, USA. Tel: +1 713 745 8631; e-mail: bgranweh@
mdanderson.org
Curr Opin Oncol 2013, 25:353–359
DOI:10.1097/CCO.0b013e3283622c32

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Supportive care
KEY POINTS

Infectious diseases consultation results in improved
outcomes in inpatient and outpatient settings.

Mortality of S. aureus bacteremia and candidemia is
reduced with infectious diseases consultation.
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Adherence with infectious diseases recommendations is
associated with improved outcomes.
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Routine infectious diseases consultation for outpatient
parenteral antibiotic therapy is associated with more
appropriate utilization of antibiotics,
including discontinuation.

Telephone, curbside, or other informal consultation is
inferior to bedside consultation, resulting in
increased mortality.
discontinuation and 24.4% initiation [3]. In
addition, there was a significant reduction in overall
antibiotic use, with consequent savings in antibiotic
costs [3]. In the ICU study, appropriate antibiotics
increased from 68.8 to 83.7% and compliance with
local guidelines increased from 63.4 to 83.8% with
infectious diseases involvement [4]. In the oncology
setting, it is even more difficult to ascertain the
value of the infectious diseases consultant because
oncology patients are often excluded from clinical
studies.
A paucity of published studies exists on the topic
of infectious diseases consultation in the cancer
setting. Some data, however, exist. For example,
an early demonstration of the utility of infectious
diseases consultation in patients with cancer was a
significant decrease in mortality from 20.5 to 9.9%
in patients with fungemia and bacteremia [5]. In this
manuscript, we discuss the impact of infectious
diseases consultations on the cancer patient popu-
lation, concentrating on direct consultation, rather
than the indirect impact from nonpatient care
activities such as infection control and antimicro-
bial stewardship [6].
AMBULATORY SETTING
Infectious diseases consultations are predominantly
sought in the inpatient setting, but outpatient con-
sultations comprise an important component of
infectious diseases practice. As patient care, includ-
ing oncology management, is increasingly shifted
from inpatient to outpatient settings, information
regarding current utilization of infectious diseases
services will assist in establishing an appropriate
role for infectious diseases consultation in the
ambulatory setting.
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In a general infectious diseases setting in Israel,
54.3% of consults were sought for management of
an established infection [7]. Viral infections,
including cytomegalovirus and herpes simplex
virus infection, accounted for 17.3% of consults,
whereas skin and soft tissue infections and gastro-
intestinal syndromes composed 15.2 and 7.6%,
respectively [7]. In contrast to the oncology set-
ting, in a general infectious diseases setting, post-
travel consultation (15.5%) and infections related
to pregnancy (11%) were issues leading to consul-
tation [7].
A study conducted in a comprehensive cancer
center described the outpatient practice of two
infectious diseases specialists from 1998 to 2008.
Among patients referred to these two specialists,
53% had a solid tumor, 8% were severely neutro-
penic, and 17% were receiving high-dose cortico-
&&
steroids [8 ]. The services that referred patients were
leukemia (15%), surgical oncology (15%), and stem
&&
cell transplantation (14%) [8 ]. In contrast to the
general infectious diseases setting, 35% of referrals
(compared to 54.3% [7]) were exclusively for man-
agement, whereas 42% were for diagnosis and man-
agement, and 22% for diagnosis alone [8 ]. The
&&
infectious diseases physicians provided alternative
diagnoses in 53% of consultations, suggesting differ-
ent types of infection in 46% and noninfectious
&&
etiologies in 29% of consults [8 ]. Similar to the
general infectious diseases setting, 14% of consul-
&&
tations were for skin and soft tissue infection [8 ]. In
contrast to the general infectious diseases setting,
diagnosis and/or management of pulmonary nod-
ules or infiltrates composed 31% of consultations,
almost twice as much as the general infectious dis-
&&
eases setting [8 ]. The infectious diseases consult-
ants initiated antimicrobial therapy in 31% and
discontinuation of antibiotics in 5% of cases [8 ].
&&
These findings, summarized in Table 1, demonstrate
the important role of infectious diseases physicians
in the oncology setting in optimizing the diagnostic
and therapeutic approach to established or sus-
pected infection.
New innovations in outpatient care include
diagnosis and prevention of reactivation of chronic
infections, such as hepatitis C virus. Exacerbation
of hepatitis C viral infection was reported in 33%
of patients in a retrospective study of patients
undergoing treatment at a major cancer center,
with increased risk of reactivation in those with
hematologic malignancy (73 vs. 29%, P < 0.001),
lymphopenia (6 vs. 0%, P ¼ 0.01), and exposure
to rituximab [odds ratio (OR) 4.2 (1.6–10.9),
P ¼ 0.004] [9]. In that same cancer center, a
hepatitis C clinic was established, with an increase
in the number of cancer patients started on therapy
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 Infectious diseases support in oncology Granwehr and Kontoyiannis

Table 1. Role of infectious diseases consultation in outpatient setting

Organism or syndrome Issues

Pulmonary nodules or infiltrates Diagnostic workup

Positive respiratory cultures for unusual pathogens: colonization vs. infection
Cellulitis and/or surgical infection Antibiotic management (duration, selection, route)
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Characterize complications or deep tissue involvement

Culture and/or serologic test Need for antimicrobials
Repeat cultures or serogy, further specialized diagnostic tests
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Hepatitis C Diagnose, characterize genotype, need for treatment

Start on treatment, monitor for reactivation while on chemotherapy
HIV Diagnosis, characterize genotype, devise treatment
Coordinate with outside providers
Modify HAART given drug–drug interactions, toxicity

&
from 3% at baseline to 19% [10 ]. Interestingly,
similar sustained virologic response rates (approxi-
mately one-third) were noted in cancer patients
compared with other difficult-to-treat patients,
&
such as solid organ transplant recipients [10 ,11],
even prior to availability of novel protease inhibi-
tors [12]. In addition to hepatitis C, the complexity
of HAART and chemotherapy in patients with
HIV/AIDS and malignancy presents a challenge
to oncologists, with many interactions potentially
leading to hepatotoxicity, neutropenia, nephro-
toxicity, or alteration in levels of HAART and/or
antineoplastic agents [13]. In summary, infectious
diseases consultation plays an increasingly import-
ant role in the ambulatory setting in the diagnosis
and management of acute and chronic infections,
ranging from pulmonary infection to skin and soft
tissue infection to hepatitis C virus infection. In
the next section, we will examine the impact of
infectious diseases consultation in the inpatient
oncology setting (Table 2).
BLOODSTREAM INFECTION
The impact of infectious diseases consultation on
oncology inpatients was established in the 1970s at
a major cancer center, in which the mortality with
infectious diseases involvement for bacteremia and
fungemia decreased to 10.6% [5]. However, the
subsequent literature describing the impact of
infectious diseases consultation on management
and outcomes of bloodstream infections did not
specifically characterize impact on cancer patients.
In a recent study conducted in the Netherlands,
appropriateness of empiric therapy for bacteremia
was described. When infectious diseases consultants

Table 2. Role of infectious diseases consultation in inpatient setting

Organism or syndrome Issues Demonstrated impact

S. aureus bacteremia Antibiotic management (duration, selection) þþþ (LOS, mortality, complications)
Identification of metastatic foci
Candidemia Antibiotic management (duration, selection) þþ (mortality, adherence to guidelines)
Identification of metastatic foci
Removal of CVC
Bloodstream infections Antibiotic management (duration, selection) þþ (mortality, identification of complications)
Identification of metastatic foci
Minimize toxicity
OPAT Discontinue unnecessary antibiotics þþþ (provide transition of care, reduce
unnecessary antibiotic use)
Optimize duration of therapy

CVC, central venous catheter; LOS, length of stay; OPAT, outpatient parenteral antibiotic therapy; S. aureus, Staphylococcus aureus.

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 Supportive care
were involved in selection of the empiric regimen,
the treatment was appropriately targeted for 75% of
isolated organisms. This stands in contrast to cases
in which infectious diseases was not consulted,
where selected regimens were adequate in only
53% of cases [14]. Based on Gram stain alone,
92% of recommendations by infectious diseases
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consultants were appropriate, increasing to 100%
when identification and susceptibility were avail-
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able [14]. The setting was one in which there was a
close relationship between the clinical microbiology
laboratory and infectious diseases consultants, with
infectious diseases becoming involved routinely in
the ICU and hematology settings [14]. In addition,
infectious diseases consultants were involved in all
cases of confirmed bacteremia.
An earlier study in a Swiss hospital of blood-
stream infection showed that infectious diseases
consultation resulted in higher rates of initiation
of therapy (100 vs. 40%, P ¼ 0.0028) and narrowing
of therapy (100 vs. 50%, P < 0.001) compared with
bloodstream infections (including fungemia) in
which infectious diseases were not involved [15].
A more recent study from Japan demonstrated a
20% reduction in 6-month relapse of infective endo-
carditis (from 22.2 to 2.2%, P ¼ 0.02) in patients for
whom infectious diseases consultation was involved
[16]. These studies confirm the important role
played by infectious diseases input in diagnosis,
management, appropriate utilization of resources,
and outcomes of bloodstream infection.
STAPHYLOCOCCUS AUREUS
BACTEREMIA
The literature regarding Staphylococcus aureus bacter-
emia is the most extensive and up to date in its
characterization of the impact of infectious diseases
consults on management and outcomes of this
common bacteria for which well established guide-
lines are available [17,18]. Specifically, infectious
diseases consultation was shown to have a consider-
able impact on various aspects of S. aureus bacter-
emia, including decrease in mortality (9–17%
&&
reduction) [19–21,22 ], better adherence to stand-
&&
ard of care (up to 34%) [22 ], decreased rate of
&&
relapse (9–19%) [22 ], and diagnosis of metastatic
foci of infection or endocarditis (10–18%) [20,21].
In another published study, propensity scores were
used to try to closely match patient characteristics
associated with infectious diseases consultation
&&
[22 ]. The authors found that infectious diseases
consultation was associated with a decreased risk of
relapse (19 vs. 10%) and increased adherence to
standard of care (89 vs. 55%). Impact on mortality
was not seen, but the authors noted that the
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infectious diseases consult service was involved in
77% of cases, making it less likely to detect a sig-
nificant difference in less-common outcomes such
&&
as mortality in this population [22 ]. Interestingly,
the authors compared the proportion of infectious
diseases consultation with prior studies and it
appeared that the impact on mortality was demon-
strated only in those with less than 51% infectious
diseases involvement with S. aureus bacteremia
[19,21,23]. Overall, infectious diseases consulta-
tion is associated with a significant impact on adher-
ence to standards of care, reduction in relapse of
infection, and mortality in studies of bloodstream
infection.
CANDIDEMIA
Studies described previously included, but did not
focus on, the impact of infectious diseases consul-
tation on patients with candidemia. A study con-
ducted in Alabama showed a 33% increase in
mortality associated with variation from guidelines
(57 vs. 24%, P ¼ 0.003) [24]. In addition, infectious
diseases consultation resulted in a 21% reduction in
6-week mortality (18 vs. 39%, P < 0.01) [24]. A study
conducted in Japan demonstrated a 34% increase
in 30-day survival (78 vs. 44%, P ¼ 0.04), 31%
increase in appropriate antifungal use (81 vs. 50%,
P ¼ 0.046), and 33% increase in appropriate
duration of therapy (95 vs. 62%, P < 0.01) [25]. A
more recent study conducted in Washington pre-
sented at Infectious Diseases Society of America
2010 in Vancouver, Washington, USA, showed a
highly significant increase in 30-day survival [haz-
ard ratio (HR) 9.03 (2.7–30.4), P ¼ 0.0004], despite a
higher severity of illness, demonstrated by APACHE
II scores over 20 (50 vs. 12%, P ¼ 0.003) when infec-
tious diseases service was consulted. The overall
impact of infectious diseases consultation on blood-
stream infections is highlighted by decreased
mortality in S. aureus bacteremia and candidemia.
The impact of infectious diseases consultation in
other syndromes, such as pneumonia, meningitis,
osteomyelitis, and/or cellulitis specifically in cancer
patients, has not been characterized. A study of
patients admitted with fever due to pneumonia,
urinary tract infection, upper respiratory infection,
and skin infection shows that an infectious diseases
admitting team performs a more aggressive workup
with higher rate of accurate diagnosis and appro-
priate antibiotics, but without significant impact on
mortality [26]. The value of infectious diseases con-
sultation in the inpatient setting continues to be a
subject of intense study, particularly as bundled
payments, and other reductions in payment to
hospitals are anticipated in the United States.
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July 2013
 Infectious diseases support in oncology Granwehr and Kontoyiannis
TRANSITION OF CARE
An area of considerable and increasing interest is the
transition between inpatient and outpatient care,
whether to a long-term care facility or the com-
munity. Infectious diseases consultation can be use-
ful in optimizing the selection and duration of
antibiotics or even discontinuing unnecessary anti-
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biotics. A teaching hospital in Massachusetts imple-
mented mandatory infectious diseases consultation
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for patients scheduled to receive outpatient paren-
teral antibiotic therapy (OPAT) [27]. The study did
not include Medicare patients because OPAT was
not funded for that population at the time of the
study. Infectious diseases consultation resulted in
change in recommendations for 88.6% of patients,
including change to oral antibiotics in 38.6%, dis-
continuation in 2.3%, change in selection in 29.6%,
change in dose in 11.4%, and duration of antibiotics
in 6.8% [27].
An institution in Ohio replicated the protocol,
requiring infectious diseases consultation for all
&&
patients scheduled to receive OPAT [28 ]. Inpatient
consultation before discharge resulted in discon-
tinuation of parenteral antibiotics in 28% of
patients [29]. Oral antibiotics were used in 17%
and 11% did not require antibiotics [29]. In
addition, outpatient infectious diseases consul-
tation was arranged for 75% of the patients, 86%
of whom were provided with outpatient parenteral
therapy and 25% of those for whom outpatient
parenteral therapy was not felt necessary [29]. Nota-
bly, no patients were readmitted or seen in the
emergency department for the same infection
during 30 days of follow-up [29]. In addition, infec-
tious diseases consultation resulted in optimization
in selection, duration, route, or discovery of psycho-
social issues that could impact therapy (e.g., intra-
venous drug use) in 84% of patients seen [28 ].
&&
Hematology and oncology service patients com-
prised only 10% of this study population. In sum-
mary, the implementation of routine infectious
diseases consultation for OPAT patients results in
reduction or optimization of antimicrobial usage
without increase in readmissions related to the
same infections.
BEDSIDE OR CURBSIDE?
The diagnosis and management of infectious dis-
eases is a cognitive process that traditionally
requires bedside evaluation by a physician who
obtains an in-depth history, physical examination,
and interprets the relevant radiology and laboratory
studies. Time and budget limitations have led to
utilization of ‘curbside’ consultations rather than
request for bedside consultation. In some settings,
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this practice may consist of up to 17% of clinical
work by an infectious diseases unit [30]. Notably,
coding of the questions arising from these ‘curbside’
consultations was considered complex in nature for
84% of inpatient and 75% of outpatient consul-
tations [30].
In a large hospital in France, a hotline was estab-
lished for infectious diseases consultation, with for-
mal consultation available on request [31]. Formal
consultation was more commonly requested for
nosocomial infection compared with community-
acquired infection (44 vs. 12%, P < 0.001) [31].
Recommendations were made to modify antimicro-
bial therapy in up to 36% of cases, particularly in
hospital settings [31]. The study was designed to
demonstrate the utility and volume of consultation
to a ‘hotline’ for consultation, not to correlate the
mechanism of consultation with outcomes.
A study in Finland, however, sought to assess the
adequacy of telephone consultation compared to
bedside consultation for management of S. aureus
&&
bacteremia [32 ]. The authors found that patients
with bedside consultation were more likely to have
deep infectious foci compared with those with tele-
&&
phone consultation (78 vs. 53%, P < 0.001) [32 ]. In
addition, mortality was lower at 7 days (1 vs. 8%,
P ¼ 0.001), 28 days (5 vs. 16%, P ¼ 0.002), and 90
days (9 vs. 29%, P < 0.001) in the bedside consul-
tation group compared with telephone consultation
&&
[32 ]. The mortality rate was considerably higher
for those with no consultation vs. bedside consul-
tation as well (5 vs. 34% 28 day mortality, P < 0.001).
On multivariate analysis, lack of infectious diseases
consultation within 1 week [OR 3.56 (1.59–7.94),
P ¼ 0.002] or telephone consultation [OR 2.31
(1.22–4.38), P ¼ 0.01] was associated with increased
90-day mortality, compared with those patients for
whom infectious diseases performed a bedside con-
&&
sultation [32 ]. In a recent study from the general
hospitalist literature in which telephone, or curb-
side, consultations were followed up by formal bed-
side consultations, authors found that information
provided by requesting providers was inaccurate or
incomplete in 51% of curbside consultations [33].
This resulted in a change of management advice for
60% of patients compared with curbside consul-
tation [33]. In summary, telephone or curbside con-
sultation, although comprising as many as 17% of
consults [30], appears inferior to bedside consul-
tation, providing inaccurate information [33] that
&&
may result in increased mortality [32 ].
COMMUNICATION AND ADHERENCE
The impact of infectious diseases consultation
in various infections and syndromes is well
www.co-oncology.com 357
 Supportive care
established. The best approach for communication
of recommendations and assuring adherence, how-
ever, continues to be explored. A survey regarding
preferences for consultation suggested that differ-
ences exist between surgical and nonsurgical teams
in preference for level of involvement, ranging from
recommendation alone to comanagement (includ-
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ing writing medications and/or diagnostic studies)
[34]. Similarly, the preferred method of communi-
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cation of recommendations is verbal for 79% of
nonsurgeons, but verbal for only 69% of surgeons
[34]. In a study in France, a survey of requesting
physicians showed that 89.8% requested communi-
cation by cell phone, 5.7% via an office ‘secretariat,’
and 4.5% via e-mail [35]. Of those seeking assistance
from infectious diseases consultants, 93% were
somewhat or very satisfied with the consultations
[35]. Methods of communication are important, but
other factors were explored regarding adherence
to recommendations.
In a study conducted in France, adherence to
antimicrobial recommendations suggested by infec-
tious diseases physicians was 88.2%, with only
72.2% adherence to diagnostic suggestions [36].
Importantly, the study showed that adherence to
recommendations for treatment was associated with
a shorter median length of stay (20 vs. 23 days,
P ¼ 0.03) and earlier clinical improvement (60.7
vs. 43.9%, P ¼ 0.01), but in-hospital mortality was
not affected [36]. In a recent study conducted in
Spain, involving a population with 41.2% patients
with malignancy, both adherence to suggestions
[OR ¼ 0.35 (0.19–0.64), P ¼ 0.001] and adequate
initial treatment [OR ¼ 0.39 (0.19–0.80), P ¼ 0.01]
were associated with clinical response [37]. In sum-
mary, direct verbal communication is preferred
through e-mail or written recommendations for
communication by most nonsurgical teams [34],
and adherence to recommendations is associated
with improved outcomes [36,37].
CONCLUSION
The value of infectious diseases consultation
for cancer patients was first described in a study
published in 1977, showing a 10% decrease
in mortality for fungemia and bacteremia [5].
Since 2005–2006, the proportion of hospitalized
patients at our tertiary cancer center for whom
infectious diseases consultation services were
sought increased from 7.0 to 13.8% in 2011–2012
(Victor Mulanovich, personal communication,
15 January 2013). Existing literature, composed
mostly of noncancer patients, showed the import-
ance of infectious diseases consultation in reducing
mortality associated with bloodstream infection,
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from S. aureus bacteremia [19] to candidemia
[24,25]. The role of infectious diseases consultation
in managing the transition from inpatient to out-
patient settings was pointed out, including discon-
tinuation of antibiotics, change to an oral agent, or
change in selection of antibiotic [27,29]. Of particu-
lar note, telephone, curbside, or other informal
consultations were associated with lower adherence
to guidelines and poorer outcomes, including
&&
mortality [32 ]. The particular knowledge and
expertise of infectious diseases consultants is sought
out not only in the inpatient (Table 2), but also the
outpatient setting (Table 1), commonly resulting in
a significant impact on the diagnostic and/or thera-
peutic approach in a variety of documented or pre-
&&
sumed infectious disease processes [8 ]. Other areas
of interest include assistance in diagnosis and man-
agement of chronic viral infections such as hepatitis
&
C [10 ] and HIV, given the complexity of drug–drug
interactions [13]. Further work needs to be done
to characterize the impact of infectious diseases
consultation specifically for cancer patients. The
value added by infectious diseases consultation in
improving outcomes, reducing drug utilization,
length of stay, and reducing readmission in an
aging, increasingly complex cancer population,
suggests that this area is a productive direction of
future research.
Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
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July 2013
 Infectious diseases support in oncology Granwehr and Kontoyiannis
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