Quantitative Analysis of the Impact of Infectious Disease Physicians on Patients in the Emergency Department Fast-Track Parenteral Antibiotics Program

doi:10.21203/rs.3.rs-3101976/v1

Download PDF

Research Article

Quantitative Analysis of the Impact of Infectious Disease Physicians on Patients in the Emergency Department Fast-Track Parenteral Antibiotics Program

https://doi.org/10.21203/rs.3.rs-3101976/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Introduction:

The outpatient parenteral antibiotic therapy (OPAT) program of Vancouver General Hospital (VGH) was supervised solely by emergency physicians (EPs) until 2017 when infectious disease (ID) physicians began assisting in management. We designed a retrospective study to determine whether ID involvement led to improved outcomes.

Methods

This study analyses the impact of this increased ID involvement by comparing the mean days patients spend on OPAT with ID involvement versus EPs alone through a retrospective chart review. Our secondary research objectives were to compare patient care decisions, e.g., antibiotic choice, tests ordered, and final diagnosis.

Results

When directly compared, there was no difference between the mean number of days on OPAT between physician types. Compared to historic patterns, patients seen in OPAT after increased ID consultation spent an average of 0.5 fewer days in the program. However, when grouped by the first day of ID assessment, the average total days in OPAT was closely aligned with the day of first ID assessment, implying that ID frequently discharged patients close to initial assessment. Patients seen by ID were less likely to return within one month of discharge compared to those not seen by ID. Secondary findings include ID physicians prescribing a greater range of antibiotics, providing more varied final diagnoses, prescribing antibiotics less frequently, and ordering more cultures, diagnostic imaging and specialist consults.

Discussion

The findings of this study support the hypothesis that ID involvement in OPAT programs leads to changes in care that may have beneficial outcomes for patients and the healthcare system.

OPAT

IV antibiotics

emergency medicine

parenteral antibiotics

cellulitis

Infectious disease involvement in OPAT decreases average days on IV antibiotics
Infectious disease physicians are less likely to prescribe antibiotics for OPAT patients
Infectious disease physicians use a greater variety of antibiotics in OPAT treatments

Outpatient parenteral antibiotic treatment (OPAT) programs have become a widespread treatment modality that significantly reduces financial burden on the healthcare system [1]. OPAT allows appropriate treatment of patients with infections that necessitate IV antibiotics, but do not require in-hospital care. Infections that are commonly treated with OPAT include: septic arthritis, osteomyelitis, infective endocarditis, cellulitis, and many others [2,3]. OPAT comes in many forms in Canada, including at-home treatment (home IV), OPAT clinics, and emergency department (ED) visits [3].

Prior to 2021, VGH – a large, quaternary-care academic medical centre in Vancouver, Canada – had an OPAT fast track model run by the ED, without routinely involving ID, to administer IV antibiotics to patients. The program involved emergency physicians (EPs) monitoring daily antibiotic administration. Patients were admitted to the OPAT program on their initial ED visit and returned (typically once daily) to receive parenteral antibiotics under the supervision of the EP on shift. Infectious disease (ID) physicians were available for consultation in difficult cases at the discretion of the EP, but this was rarely done. Beginning in the fall of 2017, ID specialists began supervision of the Fast Track program for three hours per day on weekdays, where they followed OPAT patients until discharge. While this involvement was welcomed by the EPs, it remains unknown whether it improved quality of care or patient outcomes.

We identified in a quality improvement review that moderate-to-severe cellulitis was the leading infectious diagnosis for patients in the OPAT program at VGH. We hypothesized that analysis of OPAT outcomes for patients with cellulitis at VGH would provide useful information about the benefits or detriments of ID involvement in the OPAT in general. In this study, we retrospectively assessed clinical presentations and outcomes of patients at the VGH ED OPAT program that were treated by EPs alone and those treated by ID as well as patients treated before and after the introduction of ID involvement to test the hypothesis that ID specialist input led to significant changes in practice and potentially improved patient outcomes. We aimed to determine if this direct comparison would support the permanent inclusion of ID specialists throughout OPAT programs.

A retrospective chart review of patients in the VGH ED OPAT program from November 1st 2016 to November 1st 2018 was performed. These dates were chosen to capture one year before through one year after the increased involvement of ID physicians in the OPAT program. Because of the limited hours of availability, and lack of structured presence on weekends and holidays, many patients who would otherwise see ID were instead managed by EPs alone. This distinction allowed for contemporaneous comparison of patients seen by only EPs vs those also seen by ID, reducing the potential for bias present in the temporal comparison being made.

Charts were identified by decision support using ED diagnostic codes. The inclusion criteria were patients coded as “IV antibiotics” with an initial diagnosis listed as leg cellulitis. A manual chart review was then performed. Recorded variables of the chart review included: demographic factors, such as age and gender; decisions made by attending physicians, including daily antibiotic choice and dose, consults, imaging, cultures ordered, and discharge prescription; and whether patients returned to the ED within one month of being discharged from the OPAT program. Statistical analysis was done using R and excel. programs.

Two hundred and nineteen patients met the inclusion criteria over the time-period. Of those, 81 were seen by an ID physician for at least one of the days they were in the OPAT program and 137 patients were seen by EPs alone. The ages’ ranged from 18 to 97 years of age with a mean age of 54. There was no statistically significant difference between the mean ages of patients seen by ID compared to those seen by EPs or the proportion of female to male patients between these two groups.

When patient groups were separated by whether they had been seen by ID at least once, there was no statistically significant difference between the two groups: the median number of days in the OPAT program was 4.7 (SD of 2.29) for patients seen by an ID physician at least once and 4.6 days (SD of 2.14) for patients not seen by an ID doctor (p value = 0.79). Many patients in OPAT were only seen by ID after several days being seen by EPs. To correct for this factor we calculated the mean number of days patients spent in OPAT after their first ID-supervised day and compared it to the average number of days spent in OPAT for those not seen by ID. This was statistically significant, with patients spending an average of 1.4 days (SD 1.80) in the program after being seen by ID compared to 3.4 days (SD 1.68) in the program for those not seen by ID (p < 0.0001).

Patients seen before ID involvement was formally introduced in November 2017 spent an average of 3.9 days (SD of 2.10) in the OPAT program compared to a mean of 3.4 days (SD of 2.77) for patients seen after increased ID involvement (p = 0.040). Further, being seen after increased involvement with ID was significantly associated with being switched to oral antibiotics within 5 days of IV (p = 0.026).

We compared average days in OPAT for patients categorized by the day when they first saw ID. There was a clear trend that the average number of days spent in OPAT closely aligned with the day of initial assessment by ID, which can be seen in Table 1.

Table 1

Average days in OPAT of patients based on the first day they were seen by ID
First day seen by ID:	1	2	3	4	5	6	7	8
Average days in OPAT	8.5	2.7	3.7	4.3	5.2	6.2	7.0	8.4
Average days in OPAT after ID consult	7.5	0.7	0.7	0.3	0.2	0.2	0	0.4
Number of patients seen by ID on each day (n)	2	22	12	8	5	5	2	5

Patients seen by ID physicians had more cultures taken than patients seen by EPs alone (35.3% compared to 14.2%: P < 0.0001). Cultures from patients seen by ID grew methicillin-resistant Staphylococcus aureus (MRSA), group A Streptococcus, Morganella morganii, Serratia marcescens, Klebsiella pneumoniae, and fungal pathogens more frequently. Patients not seen by ID grew methicillin-susceptible Staphylococcus aureus and Streptococcus dysgalactiae more frequently.

Patients seen by ID physicians during their OPAT visits had more imaging done than patients seen by EPs alone (26.5% compared to 18.7%: p < 0.0001). This result was consistent for CT, US and X-ray when individually assessed. However, we did not record whether the ordering physician was an EP or an ID physician or whether these images were taken before or after a patient was seen by ID. It was not feasible to assess differences in the rates of abnormal findings since the reports were narrative and the most common finding was soft tissue swelling consistent with cellulitis.

Patients seen by ID physicians had more consults ordered than patients seen by EPs alone (5.0% compared to 6.5%: p < 0.0001). Those seen by ID were more likely to have had plastic surgery and vascular surgery consults ordered (2.5% compared to 0.7%, and 1.3% compared to 0.00% respectively). Patients seen by EPs alone were more likely to have been seen by internal medicine and orthopedics (4.5% compared to 0.00%, and 1.5% compared to 1.2% respectively).

ID physicians were significantly more likely to not prescribe an antibiotic, with no antibiotic prescribed on 19.8% of the days they saw a patient compared to 1.3% of the days an EP saw a patient (P value < 0.00001).

Among antibiotics selected, EPs were more likely to prescribe the combination of daily cefazolin and probenecid, often with trimethoprim/sulfamethoxazole (TMP/SMX), or doxycycline. ID physicians were more likely to prescribe ceftriaxone, vancomycin, daptomycin, and ertapenem (Fig. 1). There were statistically significant differences in the antibiotic prescribed at discharge by ID physicians and EPs (Fig. 2): ID physicians prescribed no antibiotic 21.6% of the time compared to 16.7% for EPs (p < 0.00001). Overall, ID physicians prescribed clindamycin, ciprofloxacin, moxifloxacin, amoxicillin/clavulanic acid, cefuroxime and fluconazole more commonly.

The final diagnosis of patients seen by ID physicians varied more than those seen by EPs alone. Patients seen by only EPs had cellulitis as a final diagnosis 91.3% of the time compared to 81.5% of the time for patients seen by ID physicians. Patients seen by ID physicians were diagnosed with venous stasis, hematoma, edema, osteomyelitis, insect bites and gout more frequently than patients seen by only EPs. Only patients seen by an ID doctor received a final diagnosis of paronychia, vascular insufficiency, septic arthritis and MSK pain. Patients not seen by ID were the only ones diagnosed with post-operative complications and allergic reactions.

Lastly, patients not seen by ID were more likely to return to the OPAT program within 1 month of being discharged compared to those seen by ID (7.25% and 6.17% respectively: p < 0.0005).

Considerations that are important for monitoring an OPAT program include: correctly identifying an infection and possible causative agents; determining appropriate empiric treatments; determining when to switch to a narrower spectrum treatment, to an oral option, or stopping antibiotic treatment; microbial factors that could affect antibiotic efficacy like infection location or susceptibility; and host factors such as immune status, age, or likelihood of compliance with medication. These factors make for difficult decisions, which are complicated by evolving antimicrobial resistance. For this reason, we predicted that ID specialist involvement resulted in fewer days patients spent in the OPAT program, mitigating burden on the healthcare system and resulting in less time spent at the hospital for patients.

We focused on patients with a diagnosis of cellulitis because it was by far the leading diagnosis in our cohort. Cellulitis is most commonly caused by beta-hemolytic Streptococcus species or Staphylococcus aureus [4], although in most cellulitis cases microbiologic diagnosis is not obtained, so treatment is largely empiric. Oral cephalexin has been shown to be an appropriate treatment method for mild to moderate cases of cellulitis. Moderate to severe cases respond well to IV cefazolin [4] and can be reassessed during treatment and switched to an oral antibiotic when symptoms improve [5]. Since the organisms that cause cellulitis can have varying levels of antibiotic resistance, they may require different antibiotic treatments. However, the duration of IV antibiotics before switching to oral antibiotics will vary depending on the supervising physician. Physicians presented with the same case information in a survey had large variability in the antibiotic treatment they prescribed [6].

Additionally, diagnosing cellulitis can be difficult. Cellulitis typically presents with cutaneous erythema, warmth, tenderness, and edema; leukocytosis and elevated ESR and/or CRP can also be present but are not required for diagnosis and are often not assessed [7,8,9]. The lower extremities are the site of infection in 70–80% of cases [10]. However, the common signs and symptoms of cellulitis are common findings; therefore, many diseases can masquerade as cellulitis. Common examples of diseases misdiagnosed as cellulitis include deep vein thrombosis, contact dermatitis, gouty arthritis, and cutaneous manifestations of peripheral vasculopathy such as venous or arterial insufficiency [11; 10]. A study by David et al. showed that 28% of cellulitis diagnoses made by EPs were determined to not be cellulitis when reassessed by dermatology or ID specialists [12].

Research has shown that ID specialists are very effective at managing OPAT programs. A multicentered ID-supervised OPAT study showed that 94% of patients were effectively treated [13]. However, this study did not compare OPAT programs supervised by ID specialists to those supervised by EPs. Directly comparing outcomes of patients treated by EPs to those treated by ID specialists at the same hospital can quantify this comparative benefit. Further, assessment of ID specialists’ involvement in the VGH OPAT program has not been formally done.

The purpose of this study was to assess the impact of ID specialist involvement in the program by analyzing patient data and comparing cases monitored by ID specialists to those seen by EPs. This was done by comparing patients that received IV antibiotics in the OPAT fast-track program of VGH for lower leg cellulitis while supervised by either an ID specialist or an EP. When comparing the mean number of days patients seen by EPs alone spent in the program with those seen by ID at least once there was no statistically significant difference. However, the layout of the OPAT program at the time of our study complicates analysis of the direct impact of ID supervision on the number of days patients spend in the program. There was often substantial patient supervision overlap as ID doctors only supervised at specific times and would not supervise over weekends. Further, more clinically complicated patients or those that were predicted to have prolonged IV antibiotic requirements could often be selected for early ID supervision, which would have inflated the average number of days in the program following ID involvement. Patients that were determined to have refractory infections after not responding to IV treatment would have been referred to ID physicians after multiple days in the program without clinical response. Therefore, even if the ID physician discharged patients from the program the first day they were assessed by switching them to an oral option or determining that the pathology was not infectious in nature, the mean days in OPAT would still be elevated due to circumstances that are not reflective of ID involvement.

To mitigate some of these confounding variables we calculated how many days patients spent in the OPAT program after their first assessment by an ID specialist. We compared this to the total number of OPAT days for those seen by EPs alone, which showed that after being seen by an ID physician, patients spent a mean of 2 days less in the program compared to the number of days in OPAT for patients seen by EPs alone.

To further mitigate bias the mean number of days in the OPAT program for patients was compared with patients grouped by the day first seen by ID (Table 1). This showed that the mean number of days in the program and the day of initial ID assessment were closely aligned (except for day 1), which implies that on average patients were typically discharged from the program after initially seeing an ID doctor. This finding gives substantial support to our hypothesis that ID supervision decreases the number of days patients spend in the OPAT program. The exception to this is patients that were seen by ID on day one, but this was exceedingly rare as patients are typically seen by an EP the first time they receive IV antibiotics before being assigned to the OPAT program. Therefore, the sample size for OPAT patients that saw ID on day one was only two patients, who were likely complicated patients warranting immediate ID assessment. It is therefore likely that they would have had longer stays in OPAT for full treatment.

As a balancing measure for early discharge, we assessed repeat visits to ED within a month. Overall, being seen by ID while on OPAT was associated with a significant 14.9% reduction in returning to the hospital within one month of discharge compared to those seen by EP patients alone, showing that the lower mean days of treatment of ID supervised OPAT patients was not the result of insufficiently treated infections. There is the possibility that patients would follow up for recurrent infections at a different hospital, but this would presumably be the same for both ID and EP supervised patients.

Contemporaneous comparison of cohorts separated by the date of increased ID involvement in the OPAT program showed that patients spent an average of 0.5 days less in the OPAT program after increased ID supervision. This finding shows that ID involvement in the OPAT program did decrease the mean number of days patients spent in the OPAT program baring any significant reductions in infection severity or antibiotic resistance over time, which is unlikely. Further, when we defined a successful OPAT intervention as being switched to oral antibiotics within 5 days of IV antibiotics, the initial requirement for being referred to OPAT, then being seen after increased ID involvement was significantly associated with success (p = 0.0263).

Secondary findings of our study were that ID physicians had greater variety in the antibiotics they prescribed, the final diagnosis patients received, and the organisms cultured. The larger variety in antibiotic prescription could be due to increased comfort with a wider assortment of antibiotics, which would allow more assurance with narrower spectrum antibiotic treatments. The antibiotic choices reflected more narrow spectrum antibiotic agents to target specific pathogens and less reliance on empiric treatment with cefazolin. Patients seen by EPs alone were not prescribed ertapenem during this period. This is likely because any complex cases that may require ertapenem would have prompted an ID referral.

ID physicians were more likely to not prescribe antibiotics and to discharge people from the program without any continuing oral antibiotics. Typically, patients being discharged from the program would be the only patients that would not receive IV antibiotics. This could be a reflection of when patients are assessed, i.e. if patients on OPAT are seen by a physician before they are given antibiotics or after. ID physicians would routinely do an assessment before any antibiotics were ordered. In comparison, EPs were also responsible for seeing emergency patients and therefore OPAT patients were commonly given IV treatments on arrival to the OPAT program while they waited to be assessed by an EP each day. However, this could also be because ID doctors felt more confident determining cases that would not amenable to further antibiotic treatment, be that because of an alternative diagnosis or a chronic ailment that would continue to have some baseline superficial infection like a diabetic wound.

EP physicians had fewer cultures taken, less imaging done and fewer consults ordered. This could be due to more comfort making clinical acumen decisions based on the increased volume of patients that EPs see, as well as the increased mindfulness of medical costs that is more paramount with increased patient volume. However, it is also possible that these tests were ordered less frequently because ID would typically be involved at this point and the decisions could be left to them to make. Further, it should be noted that the increased cultures ID ordered likely contributed to being able to use a greater variety of antibiotics.

In addition, the higher frequency of consultation of internal medicine by EPs could be an artifact of the admission process in our hospital, since patients referred for admission to the internal medicine Clinical Teaching Units would require an internal medicine consult. It is thus possible that the sickest patients— such as those failing initial outpatient treatment or with positive blood cultures at their first visit–were selected for hospital admission by the EPs in lieu of continued OPAT visits and subsequent ID assessment. In contrast, the increased consultation of vascular and plastic surgery by ID could reflect the more complex nature of diabetic foot infections (typically managed by vascular surgery or plastic surgery) which could be more likely to have been referred for ID involvement and/or to require longer antibiotic courses.

In conclusion, the involvement of ID decreased the average number of days patients spent in the OPAT program without increasing the number of patients that returned to the ED due to insufficiently treated infections. However, the design of the OPAT program added multiple confounding variables that complicates direct comparison. Further analysis did show strong support for our hypothesis. This analysis was based on temporal comparisons of days patients spent in OPAT prior to increased ID involvement compared to after, which showed a reduction in the mean days in the program by 0.5 days. As well, comparing the number of days patients spent in OPAT after initial ID assessment showed an overall trend of the average days spent in OPAT being closely aligned with the first day they were seen by ID, implying that many patients were sent home on or close to the day they were first seen by ID. After this study was completed, an ID-supervised OPAT program was instituted, which will provide opportunity for further comparisons with far fewer confounding variables to provide additional support to the findings of our study. Our secondary findings showed greater variety in the antibiotics ID physicians prescribed, the final diagnoses patients received, and the organisms cultured. Further, ID physicians prescribed antibiotics less frequently. Conversely EP physicians ordered fewer cultures, less imaging and fewer consults. An area for further study would be detailed comparisons and analyses of the secondary findings of our study. An increased sample size and more resources could elucidate implications and causes for these findings.

Ethics approval and consent to participate

All methods were carried out in accordance with relevant guidelines and regulations.

All experimental protocols were approved by a Vancouver Costal Health Research Institute ethics as well as the University of British Columbia Clinical Research Ethics Board.

UBC ethics number: H18-03264.

VCH number: V18-03264

Informed consent was not required as per our intuition’s clinical research guidelines as patient information was deidentified according to protocols for our chart review.

Article 5.5A, TCPS2, states: “Researchers who have not obtained consent from participants for secondary use of identifiable information shall only use such information for these purposes if they have satisfied the REB that:

a. identifiable information is essential to the research;

b. the use of identifiable information without the participants’ consent is unlikely to adversely affect the welfare of individuals to whom the information relates;

c. the researchers will take appropriate measures to protect the privacy of individuals, and to safeguard the identifiable information;

d. the researchers will comply with any known preferences previously expressed by individuals about any use of their information;

e. it is impossible or impracticable to seek consent from individuals to whom the information relates; and

f. the researchers have obtained any other necessary permission for secondary use of information for research purposes.”

We have satisfied these requirements as per review by the Vancouver Coastal Health Research Institute ethics review board.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due confidentiality but are available from the corresponding author on reasonable request in de-identified form.

The datasets supporting the conclusions of this article are submitted as additional files for peer review.

Competing interests

The authors have no relevant financial or non-financial interests to disclose.

Funding

The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study.

Author’s contributions

The authors confirm contribution to the paper as follows: study conception and design: C. McSweeney, T. Steiner, J. M. Grant; data collection: C. McSweeney; analysis and interpretation of results: C. McSweeney; draft manuscript preparation: C. McSweeney. All authors reviewed the results and approved the final version of the manuscript.

Acknowledgements

We thank Dr. Heather Lindsey Department Head of VGH Emergency Medicine as well as the team at the Vancouver Coastal Health Research Institute.

Paladino JA, & Poretz D. Outpatient Parenteral Antimicrobial Therapy Today. Clinical Infectious Diseases, 51(S2), S198–S208. 2010; https://doi.org/10.1086/653520
Chapman ALN, Mortlock NJ, & Schleis T. Outpatient parenteral antimicrobial therapy. BMJ, 12(4), f1585–f1585. 2013; https://doi.org/10.1136/bmj.f1585
Laupland KB, & Valiquette L. Outpatient parenteral antimicrobial therapy. Can J Infect Dis Med Microbiol (Vol. 24). 2013; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3630020/pdf/jidmm24009.pdf
Seaton RA, Sharp E, Bezlyak V, & Weir CJ. Factors associated with outcome and duration of therapy in outpatient parenteral antibiotic therapy (OPAT) patients with skin and soft-tissue infections. International Journal of Antimicrobial Agents, 38(3), 243–248. 2011 https://doi.org/10.1016/j.ijantimicag.2011.05.008
Spelman D, Baddour L, Lowy D, Baron L. Clinical approach to management of nonpurulent cellulitis in adults. UpToDate. 2018; http://www.uptodate.com
Abuhussain SA, Krawczynski M, Tart S, Jacknin G, Kohman K, Hobbs AL, Nailor MD, Keyloun KR, Nicolau DP, Kuti JL. Variability in Emergency Medicine (EM) Provider Decisions on Hospital Admission and Antibiotic (ABX) Treatment for Acute Bacterial Skin and Skin Structure Infections (ABSSSI). Open Forum Infectious Diseases, 4(suppl_1), S254–S254. 2017; https://doi.org/10.1093/ofid/ofx163.550
Krasagakis K, Valachis A, Maniatakis P, Krüger-Krasagakis S, Samonis G, & Tosca AD. Analysis of epidemiology, clinical features and management of erysipelas. International Journal of Dermatology, 49(9), 1012–1017. 2010; https://doi.org/10.1111/j.1365-4632.2010.04464.x
Lazzarini L, Conti E, Tositti G, & de Lalla F. Erysipelas and cellulitis: Clinical and microbiological spectrum in an Italian tertiary care hospital. Journal of Infection, 51(5), 383–389. 2005; https://doi.org/10.1016/j.jinf.2004.12.010
Vata D, Solovastru LG, Vata A, & Dorobat C. [Demographic, clinical and laboratory characteristics of erisypelas in the period 2001-2010]. Erizipelul--Caracteristici Demografice, Clinice Si Paraclinice in Perioada 2001-2010., 115(4), 1042–1047. 2011; http://www.ncbi.nlm.nih.gov/pubmed/22276443
Hirschmann JV, & Raugi GJ. Lower limb cellulitis and its mimics: Part II. Conditions that simulate lower limb cellulitis. Journal of the American Academy of Dermatology, 67(2). 2012; https://doi.org/10.1016/j.jaad.2012.03.023
Falagas ME, & Vergidis PI. Narrative review: Diseases that masquerade as infectious cellulitis. Annals of Internal Medicine. American College of Physicians. 2005; https://doi.org/10.7326/0003-4819-142-1-200501040-00011
David CV, Chira S, Eells SJ, Ladrigan M, Papier A, Miller LG, & Craft N. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatology Online Journal, 17(3), 1. 2011; http://www.ncbi.nlm.nih.gov/pubmed/21426867
Petrak RM, Skorodin NC, Fliegelman RM, Hines DW, Chundi VV, & Harting BP. Value and Clinical Impact of an Infectious Disease-Supervised Outpatient Parenteral Antibiotic Therapy Program. Open Forum Infectious Diseases, 3(4), ofw193. 2016; https://doi.org/10.1093/ofid/ofw193

No competing interests reported.

Download PDF

Editorial decision: Revision requested
20 Nov, 2023
Reviews received at journal
16 Oct, 2023
Reviews received at journal
15 Oct, 2023
Reviews received at journal
15 Oct, 2023
Reviewers agreed at journal
13 Oct, 2023
Reviewers agreed at journal
01 Oct, 2023
Reviewers agreed at journal
28 Sep, 2023
Reviewers invited by journal
28 Sep, 2023
Editor assigned by journal
13 Sep, 2023
Editor invited by journal
23 Jul, 2023
Submission checks completed at journal
23 Jul, 2023
First submitted to journal
23 Jun, 2023

You are reading this latest preprint version

Quantitative Analysis of the Impact of Infectious Disease Physicians on Patients in the Emergency Department Fast-Track Parenteral Antibiotics Program

Status:

Version 1

Abstract

Introduction:

Methods

Results

Discussion

Figures

Highlights

Introduction

Methods

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1