For Many Infections, Source Control Is Key

 If you're in a specialty that asks for infectious disease (ID) consultations, you've probably been on the receiving end of a recommendation for source control. Indeed, some infections show little to no benefit from antibiotics without an accompanying intervention, whereas others require no antibiotics at all once surgical source control has been accomplished.

Source control is the key to successful management of many infections because it: (a) offers direct evacuation or reduction of infectious foci; (b) reduces bacterial load; (c) allows debridement of devitalized tissue, which helps restore proper physiologic function; (d) removes infected devices or foreign materials; and (e) enhances antibiotic delivery to a site of infection.

Patients who undergo efficient and effective source control exhibit faster resolution of sepsis symptoms and demonstrate improved patient outcomes; in addition, they often can be treated with shorter antibiotic courses (or no antibiotics at all), which may lessen the influence on antimicrobial resistance.

Yet, I often find the "push and pull" conversations about source control, usually prompted by a requested ID consultation, to be one of the most stressful parts of my workday. Rest assured, I don't recommend source control lightly — I'd love to help a patient avoid an invasive procedure, device removal, or surgical intervention too. It is just the unfortunate truth that some infections cannot be cured without these measures (and in some cases, a delay in such measures is truly life-threatening).

As specialists in IDs, we've been trained to recognize infections that necessitate source control. We've studied the limitation of antibiotics when used alone vs when used in combination with source control. We've read the studies that confirm improved outcomes with prompt debridement, drainage, or device removal. And we've witnessed the patients who have suffered from ongoing pain, persistent sepsis, irreversible tissue destruction, or even death when source control has been deferred or could not be performed.

Over the years, the discussions with other providers about source control have become both more frequent and more tense. While this may be a personal perception, I've overheard colleagues in infectious diseases and other specialties express similar sentiments. I'm sure there are many varied (and provider-dependent) reasons for this shift. But admittedly, it can sometimes be difficult for those of us in nonsurgical specialties to understand an increased reluctance to proceed with source control.

Sometimes, all of the providers on a patient's multidisciplinary team feel that source control of an infection would be ideal, but the necessary intervention is unfortunately unable to be performed. More often, though, the various specialties reach an impasse. For example, the primary team and/or ID service might feel strongly that source control is needed for clinical improvement and an attempt at a cure, but the surgical service does not agree that an intervention is warranted or possible. At this point, the conversations between team members and between providers and patients can be tricky to navigate.

Sometimes, I've been told to "stay in your lane" when I've suggested that an intervention is highly recommended for a certain infection. Other times, I've been told that a patient is not a surgical candidate for source control, even though they've been cleared for surgery by their primary service. I've had a general surgeon tell me that he wouldn't take an otherwise healthy but actively bacteremic/septic patient with a loculated gluteal abscess for debridement because he "didn't want to risk introducing a new infection."

Medical students and residents on the ID service are sometimes part of these source control conversations, and they've expressed concern about engaging in such difficult discussions in the future. How do we best convey our clinical and surgical opinions to each other so that appropriate and timely treatment decisions can be made? And how can providers ensure that their patients aren't caught in the middle when those opinions differ? Unfortunately, I don't have the perfect answers to these questions.

My strategy is to make sure the ID team reviews the entire patient chart so that we've heard all sides of the conversation about the management of infection. I share why I feel strongly about source control with the students and residents, and we make those concerns known directly to the patient's other providers. We talk about the expected efficacy of antibiotics when used alone compared with their use in conjunction with source control. And I expect students and residents to be able to weigh the theoretical risks for intervention against the real-time risks for a potentially life-threatening infection.

Hopefully, my colleagues in other specialties (both surgical and non-surgical) are doing the same: fully reviewing the patient's chart, having respectful discourse with other team members about infectious management, addressing the limitations of antibiotics, and assessing theoretical vs actual risks when considering interventions for source control. It's what our patients deserve and it's what we, as antimicrobial stewards, should willingly do.

Roni K. Devlin, MD, MBS, is an infectious diseases physician currently residing in the Midwest. She is the author of several scholarly papers and two books on influenza. With a longstanding interest in reading and writing beyond the world of medicine, she has also owned an independent bookstore, founded a literary nonprofit, and published articles and book reviews for various online and print publications. 

https://www.medscape.com/viewarticle/978848