402 29% of total cases involved them. Furthermore, MRSA was not the leading cause of VGI within our cohort as is described in other observational studies.6 This observation may be secondary to the increase in screening and preoperative eradication of MRSA colonisation, appropriate perioperative prophylaxis and the use of glycopeptide antibiotics peri-operatively within our trust.7,8 The observation of a high proportion of gram negative causative organisms supports the observations by Szczot and colleagues1 in their review of ICU patients. Further longitudinal work is required to understand whether peri-operative gram negative cover with aminoglycoside therapy would influence these findings given the high proportion of gram negative causative organisms we identified as causing early VGI (n Z 6/10; 60% all early VGI). Given the limitations of our study, including the retrospective nature and small number of VGI identified we are proposing to undertake further prospective longitudinal work to allow for identification of temporal relationships between micro-organisms, antimicrobial treatment and surgical interventions and more accurate characterisation of development of antimicrobial resistance.
Conflicts of interest We have no conflicts of interest to declare in this project.
Acknowledgements We would like to thank Dr R Davidson, Dr L John & the radiology department at NWPH for their support in this project.
Letters to the Editor 8. National Health Service, Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation. A strategy for NHS trusts: a summary of best practice. http://webarchive. nationalarchives.gov.uk/20130107105354/http://www.dh.gov. uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ documents/digitalasset/dh_063187.pdf. (accessed 12/10/2014). 9. Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012;18:268e81.
Timothy M. Rawson* Ming J. Lee Department of Medicine, Northwick Park Hospital, 1053 Great Western Road, Harrow HA1 3UJ, UK Priya Khanna Guduru Gopal Rao Department of Microbiology, Northwick Park Hospital, 1053 Great Western Road, Harrow HA1 3UJ, UK Sophie Renton Department of Vascular Surgery, Northwick Park Hospital, 1053 Great Western Road, Harrow HA1 3UJ, UK Jim Buckley Department of Infectious Disease, Northwick Park Hospital, 1053 Great Western Road, Harrow HA1 3UJ, UK *Corresponding author. Imperial College London, London, UK. Tel.: þ44 07891750151 (mobile).
E-mail address: [email protected] (T.M. Rawson)
References 1. Szczot M, Meybeck A, Legout L, Pasquet A, Van Grunderbeeck N, Langlois J, et al. Vascular graft infections in the intensive care unit: clinical spectrum and prognostic factors. J Infect 2011;62(3):204e11. 2. Legout L, Sarraz-Bournet B, D’Elia PV, Devos P, Pasquet A, Caillaux M, et al. Characteristics and prognosis in patients with prosthetic vascular graft infection: a prospective observational cohort study. Clin Microbiol Infect 2012;18:352e8. 3. Hasse B, Husmann L, Zinkernagel A, Weber R, Lachat M, Mayer D. Vascular graft infections. Swiss Med Wkly 2013;143: w13754. 4. Samson RH, Veith FJ, Janko GS, Gupta SK, Scher LA. A modified classification and approach to the management of infections involving peripheral arterial prosthetic grafts. J Vasc Surg 1988;8(2):147e53. 5. Stone PA, Back MR, Armstrong PA, Brumberg RS, Flaherty SK, Johnson BL, et al. Evolving microbiology and treatment of extracavitary prosthetic graft infections. Vasc Endovasc Surg 2008;42:537e44. 6. Taylor MD, Napolitano LM. Methicillin-resistant Staphylococcus aureus infections in vascular surgery: increasing prevalence. Surg Infect 2004;5(2):180e7. 7. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE. Guidelines for the prophylaxis and treatment of methiclillin-resistant Stphylococcus auresu (MRSA) infections in the UK. J Antimicrob Chemother 2006;57:589e608.
Accepted 16 April 2015 http://dx.doi.org/10.1016/j.jinf.2015.04.008 ª 2015 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
elCID: An electronic Clinical Infection Database to support integrated clinical services and research in infectious diseases
Dear Editor King and colleagues recently reported in this Journal their use of electronic syndromic surveillance for the management of surgical infection, highlighting the potential of routine data collection to improve clinical services and inform research within infectious disease practice.1 The care of patients with infectious diseases is complex and frequently dependent on multi-disciplinary input from infectious diseases physicians, microbiologists and virologists.2,3 These teams add significant value4 and
Letters to the Editor result in improved patient outcomes and reduced expenditure.5,6 Data collected on these different aspects of the clinical service are fragmented across patient lists, paper records of phone or clinical consultations, and isolated electronic databases of patients attending specialist outpatient services, such as Outpatient Parenteral Antimicrobial Therapy (OPAT). As a result, routine clinical data are often not collected systematically or in a format that can be interrogated easily to derive meaningful insights into teams’ clinical activity.7 This fragmented data collection creates a barrier to gathering large, prospective datasets that can be used to shape clinical practice, drive audit and facilitate research.7 This is further compounded by shortcomings in traditional performance metrics, such as length of stay or the number of patients seen in outpatient clinics, which fail to reflect the significant volume of clinical workload provided by infection teams through key services such as ward consultations and antibiotic stewardship. We developed an integrated clinical data entry system, the electronic Clinical Infection Database (elCID),8 that allows real-time prospective data collection of clinical activity in our Division of Infection. The database is accessed via a web browser, which allows both multiple user and remote access to elCID whilst storing all information behind the Trust’s secure firewall. The system is used to maintain inpatient lists, record consultations, and track patients seen in specialist clinics such as the OPAT service. Integral to the system is the ability to capture coded entries within all fields, in particular diagnoses, antimicrobials and investigations, thereby facilitating robust prospective data collection. The main purpose of introducing elCID was to capture the full spectrum of clinical workload across an infection service at a large tertiary referral centre. To that effect, elCID brings together disparate silos of clinical data collection into a single, rapidly searchable database resource permitting unprecedented interrogation of our clinical practice. However, the benefits of the system go further, having vastly improved the quality and transparency of communication between the Division’s teams, audits of day-to-day clinical practice are now rapidly and routinely performed using high quality prospectively collected data, and research study data collection can be conducted within the main database, facilitating improved integration of the clinical and academic arms of the Division. We have provided three case studies to illustrate the impact of elCID.
403 Table 1 Summary characteristics of patient population recorded on elCID including sources of underlying infection, cultured organisms and prescribed antimicrobials. Age Median MineMax Interquartile range
50 0e95 34e65
Source of infection Urinary tract Skin & soft tissue Respiratory Tropical Gastrointestinal Blood stream Bone þ joint Neurological Other Cardiac
% of patients 20 20 20 10 7 5 4 3 3 1
Organisms cultured from sterile site Escherichia coli Pseudomonas aeruginosa Klebsiella sp Coagulase negative staphylococcus Staphylococcus aureus Enterococcus sp Alpha haemolytic streptococci Candida sp Enterobacter sp Beta haemolytic streptococci Streptococcus pneumoniae Stenotrophomonas sp
% of cultured organisms 19 11 9 8
Antimicrobials prescribed Piperacillin tazobactam Meropenem Co-Amoxiclav Teicoplanin Ciprofloxacin Cefuroxime Flucloxacillin Gentamicin Clarithromycin Metronidazole Ceftriaxone Clindamycin
% of total antibiotics 17 8 6 6 5 5 5 4 4 3 3 3
8 5 5 4 4 2 2 2
Case study 1: impact of elCID on division workflow and quality of service delivery Utilising elCID, we were able to visualise an output of the departmental workload generated in real-time. This permitted us to both quantify our caseload to hitherto unachievable levels of accuracy (Table 1), but also demonstrate the interconnectedness and multidisciplinary nature of care provided to all 2589 patients (Figure 1). This step change in performance metrics has enabled the Division to reassess workload requirements, including the redeployment of junior doctors across our
various teams. Concurrently, elCID has also facilitated a number of improvements to the delivery of routine clinical care. Ward- and telephone-based clinical advice is now remotely accessible and searchable. Free-text searching has revealed that around 10% of clinical reviews recommended stopping antimicrobial prescriptions, an intervention difficult to quantify from paper records. In addition, the system can automatically transfer coded clinical information between inpatient and outpatient
404
Letters to the Editor
Figure 1 Network diagram representation of clinical input (edges) into individual patient episodes (blue nodes) by different Infection teams at UCLH (red nodes). Dark blue nodes represent patient episodes involving one clinical team and light blue nodes represent patient episodes involving >one clinical team.
episodes resulting in significant time-savings across patient’s complete clinical journey.
Case study 2: haematology consult service Records of the clinical liaison service offered for patients with haematological malignancies had previously been captured on hand-written T-Cards. The switch to elCID has revolutionised our ability to capture and interrogate this dataset. In the first 12 months of elCID use, the haematology service generated 3674 clinical reviews from which clinical advice was offered on 1490 occasions. The clinical reviews also resulted in 799 antimicrobial prescription changes and infection control advice being offered directly during these ward rounds on 362 occasions. These figures are in sharp contrast to attempts to derive such information pre-elCID, namely a timeconsuming, manual review of a limited subset of T-cards and subsequent extrapolation from a potentially unrepresentative and biased sample. In addition to the benefits of improved data capture, the system has improved provision
of care for this patient cohort. By definition, the previous T-Card based system relied on single user, physical data capture that limited real-time collaborative reviews and clinical input into the care of patients. The switch to elCID has allowed faster, more detailed recording of clinical interactions that are remotely and contemporaneously accessible to clinicians in both microbiology and haematology departments.
Case study 3: integrated clinical research platform The modular nature of elCID allows research data to be collected alongside routine clinical data, reducing the need for additional research specific databases. Userspecific access rights allow additional components of the database to be restricted to clinicians and academics participating in studies whilst simultaneously linking this research data to patients’ underlying routine clinical data. As data are captured prospectively in a coded format, the system provides a platform to identify
Letters to the Editor individuals meeting specified criteria and trigger referral to research nurses or additional data collection. Utilisation of such functionality helps to bridge gaps between provision of clinical care and participation in research, and has specifically been exploited by the Rapid Identification of Respiratory Tract Infection (RiD-RTI) European FP7 project that utilises elCID to both identify eligible patients for the study, as well as anonymously process and record research data collection.9
Conclusions Fragmented data presents a barrier to high quality patient care, service evaluation and research. The development of elCID has resulted in an integrated platform to address these key unmet needs, and its utilisation has provided a platform to both drive clinical service delivery and undertake audit and research. Adoption of elCID, or development of similar solutions, to record clinical activity should be considered widely across other Trusts in the UK with similar visions for data-driven improvement in quality and care delivery.
Funding This work is supported by NIHR Biomedical Research Centre funding to UCLH and UCL, and by Wellcome Trust Clinical Research Fellowships to MM (WT102807) and GP (WT101766). The funding agencies had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflict of interest DM and CR are employees of Open Health Care UK (OHCUK), the company that designed elCID. The other authors have no financial relationship with OHCUK.
References 1. King C, Aylin P, Moore LSP, Pavlu J, Holmes A. Syndromic surveillance of surgical site infectionsea case study in coronary artery bypass graft patients. J Infect 2014;68:23e31. 2. Petrak Russell M, Sexton Daniel J, Butera Michael L, Tenenbaum Marvin J, MacGregor Mary C, Schmidt Mary E, et al. The value of an infectious diseases specialist. Clin Infect Dis Off Publ Infect Dis Soc Am 2003;36(8):1013e7. http: //dx.doi.org/10.1086/374245. 3. Bursle EC, Playford EG, Looke DFM. Infectious diseases consultations at an Australian tertiary hospital: a review of 11,511 inpatient consultations. Intern. Med J 2014;44: 998e1004. 4. Vehreschild JJ, Morgen G, Cornely OA, Hartmann P, Koch S, Kalka-Moll W, et al. Evaluation of an infectious disease consultation programme in a German tertiary care hospital. Infection 2013;41(6):1121e8. http://dx.doi.org/10.1007/s15010-0130512-1. 5. Schmitt Steven, McQuillenDaniel P, Nahass Ronald, Martinelli Lawrence, Rubin Michael, Schwebke Kay, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs. Clin Infect
405
6.
7.
8. 9.
Dis Off Publ Infect Dis Soc Am 2014;58(1):22e8. http: //dx.doi.org/10.1093/cid/cit610. Sharma R, Loomis W, Brown RB. Impact of mandatory inpatient infectious disease consultation on outpatient parenteral antibiotic therapy. Am J Med Sci 2005;330:60e4. De Lusignan S, Hague N, van Vlymen J, Kumarapeli P. Routinely-collected general practice data are complex, but with systematic processing can be used for quality improvement and research. Inf Prim Care 2006;14:59e66. Electronic clinical infection database (elCID). at . RiD-RTI Rapid identification of respiratory tract infections. at .
Michael Marks1 Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK The Hospital for Tropical Diseases, Mortimer Market Centre, Mortimer Market, Capper Street, London, UK Gabriele Pollara1 Department of Microbiology, University College London Hospital, 235 Euston Road, London, UK Division of Infection and Immunity, University College London, Cruciform Building, Gower Street, London, UK David Miller Open Health Care UK, Unit 3 127 Stoke Newington Road, London, UK Sonia Bhatt Department of Microbiology, University College London Hospital, 235 Euston Road, London, UK Carl Reynolds Open Health Care UK, Unit 3 127 Stoke Newington Road, London, UK Vanya Gant Department of Microbiology, University College London Hospital, 235 Euston Road, London, UK Mahdad Noursadeghi* Division of Infection and Immunity, University College London, Cruciform Building, Gower Street, London, UK *Corresponding author. Division of Infection and Immunity, University College London, Cruciform Building, Gower Street, London, UK.
E-mail address: [email protected] (M. Noursadeghi) Accepted 10 April 2015 http://dx.doi.org/10.1016/j.jinf.2015.04.007 ª 2015 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
1 Michael Marks and Gabriele Pollara contributed equally to this manuscript.
Conflicts of interest We have no conflicts of interest to declare in this project.
Acknowledgements We would like to thank Dr R Davidson, Dr L John & the radiology department at NWPH for their support in this project.
Letters to the Editor 8. National Health Service, Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation. A strategy for NHS trusts: a summary of best practice. http://webarchive. nationalarchives.gov.uk/20130107105354/http://www.dh.gov. uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ documents/digitalasset/dh_063187.pdf. (accessed 12/10/2014). 9. Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012;18:268e81.
Timothy M. Rawson* Ming J. Lee Department of Medicine, Northwick Park Hospital, 1053 Great Western Road, Harrow HA1 3UJ, UK Priya Khanna Guduru Gopal Rao Department of Microbiology, Northwick Park Hospital, 1053 Great Western Road, Harrow HA1 3UJ, UK Sophie Renton Department of Vascular Surgery, Northwick Park Hospital, 1053 Great Western Road, Harrow HA1 3UJ, UK Jim Buckley Department of Infectious Disease, Northwick Park Hospital, 1053 Great Western Road, Harrow HA1 3UJ, UK *Corresponding author. Imperial College London, London, UK. Tel.: þ44 07891750151 (mobile).
E-mail address: [email protected] (T.M. Rawson)
References 1. Szczot M, Meybeck A, Legout L, Pasquet A, Van Grunderbeeck N, Langlois J, et al. Vascular graft infections in the intensive care unit: clinical spectrum and prognostic factors. J Infect 2011;62(3):204e11. 2. Legout L, Sarraz-Bournet B, D’Elia PV, Devos P, Pasquet A, Caillaux M, et al. Characteristics and prognosis in patients with prosthetic vascular graft infection: a prospective observational cohort study. Clin Microbiol Infect 2012;18:352e8. 3. Hasse B, Husmann L, Zinkernagel A, Weber R, Lachat M, Mayer D. Vascular graft infections. Swiss Med Wkly 2013;143: w13754. 4. Samson RH, Veith FJ, Janko GS, Gupta SK, Scher LA. A modified classification and approach to the management of infections involving peripheral arterial prosthetic grafts. J Vasc Surg 1988;8(2):147e53. 5. Stone PA, Back MR, Armstrong PA, Brumberg RS, Flaherty SK, Johnson BL, et al. Evolving microbiology and treatment of extracavitary prosthetic graft infections. Vasc Endovasc Surg 2008;42:537e44. 6. Taylor MD, Napolitano LM. Methicillin-resistant Staphylococcus aureus infections in vascular surgery: increasing prevalence. Surg Infect 2004;5(2):180e7. 7. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE. Guidelines for the prophylaxis and treatment of methiclillin-resistant Stphylococcus auresu (MRSA) infections in the UK. J Antimicrob Chemother 2006;57:589e608.
Accepted 16 April 2015 http://dx.doi.org/10.1016/j.jinf.2015.04.008 ª 2015 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
elCID: An electronic Clinical Infection Database to support integrated clinical services and research in infectious diseases
Dear Editor King and colleagues recently reported in this Journal their use of electronic syndromic surveillance for the management of surgical infection, highlighting the potential of routine data collection to improve clinical services and inform research within infectious disease practice.1 The care of patients with infectious diseases is complex and frequently dependent on multi-disciplinary input from infectious diseases physicians, microbiologists and virologists.2,3 These teams add significant value4 and
Letters to the Editor result in improved patient outcomes and reduced expenditure.5,6 Data collected on these different aspects of the clinical service are fragmented across patient lists, paper records of phone or clinical consultations, and isolated electronic databases of patients attending specialist outpatient services, such as Outpatient Parenteral Antimicrobial Therapy (OPAT). As a result, routine clinical data are often not collected systematically or in a format that can be interrogated easily to derive meaningful insights into teams’ clinical activity.7 This fragmented data collection creates a barrier to gathering large, prospective datasets that can be used to shape clinical practice, drive audit and facilitate research.7 This is further compounded by shortcomings in traditional performance metrics, such as length of stay or the number of patients seen in outpatient clinics, which fail to reflect the significant volume of clinical workload provided by infection teams through key services such as ward consultations and antibiotic stewardship. We developed an integrated clinical data entry system, the electronic Clinical Infection Database (elCID),8 that allows real-time prospective data collection of clinical activity in our Division of Infection. The database is accessed via a web browser, which allows both multiple user and remote access to elCID whilst storing all information behind the Trust’s secure firewall. The system is used to maintain inpatient lists, record consultations, and track patients seen in specialist clinics such as the OPAT service. Integral to the system is the ability to capture coded entries within all fields, in particular diagnoses, antimicrobials and investigations, thereby facilitating robust prospective data collection. The main purpose of introducing elCID was to capture the full spectrum of clinical workload across an infection service at a large tertiary referral centre. To that effect, elCID brings together disparate silos of clinical data collection into a single, rapidly searchable database resource permitting unprecedented interrogation of our clinical practice. However, the benefits of the system go further, having vastly improved the quality and transparency of communication between the Division’s teams, audits of day-to-day clinical practice are now rapidly and routinely performed using high quality prospectively collected data, and research study data collection can be conducted within the main database, facilitating improved integration of the clinical and academic arms of the Division. We have provided three case studies to illustrate the impact of elCID.
403 Table 1 Summary characteristics of patient population recorded on elCID including sources of underlying infection, cultured organisms and prescribed antimicrobials. Age Median MineMax Interquartile range
50 0e95 34e65
Source of infection Urinary tract Skin & soft tissue Respiratory Tropical Gastrointestinal Blood stream Bone þ joint Neurological Other Cardiac
% of patients 20 20 20 10 7 5 4 3 3 1
Organisms cultured from sterile site Escherichia coli Pseudomonas aeruginosa Klebsiella sp Coagulase negative staphylococcus Staphylococcus aureus Enterococcus sp Alpha haemolytic streptococci Candida sp Enterobacter sp Beta haemolytic streptococci Streptococcus pneumoniae Stenotrophomonas sp
% of cultured organisms 19 11 9 8
Antimicrobials prescribed Piperacillin tazobactam Meropenem Co-Amoxiclav Teicoplanin Ciprofloxacin Cefuroxime Flucloxacillin Gentamicin Clarithromycin Metronidazole Ceftriaxone Clindamycin
% of total antibiotics 17 8 6 6 5 5 5 4 4 3 3 3
8 5 5 4 4 2 2 2
Case study 1: impact of elCID on division workflow and quality of service delivery Utilising elCID, we were able to visualise an output of the departmental workload generated in real-time. This permitted us to both quantify our caseload to hitherto unachievable levels of accuracy (Table 1), but also demonstrate the interconnectedness and multidisciplinary nature of care provided to all 2589 patients (Figure 1). This step change in performance metrics has enabled the Division to reassess workload requirements, including the redeployment of junior doctors across our
various teams. Concurrently, elCID has also facilitated a number of improvements to the delivery of routine clinical care. Ward- and telephone-based clinical advice is now remotely accessible and searchable. Free-text searching has revealed that around 10% of clinical reviews recommended stopping antimicrobial prescriptions, an intervention difficult to quantify from paper records. In addition, the system can automatically transfer coded clinical information between inpatient and outpatient
404
Letters to the Editor
Figure 1 Network diagram representation of clinical input (edges) into individual patient episodes (blue nodes) by different Infection teams at UCLH (red nodes). Dark blue nodes represent patient episodes involving one clinical team and light blue nodes represent patient episodes involving >one clinical team.
episodes resulting in significant time-savings across patient’s complete clinical journey.
Case study 2: haematology consult service Records of the clinical liaison service offered for patients with haematological malignancies had previously been captured on hand-written T-Cards. The switch to elCID has revolutionised our ability to capture and interrogate this dataset. In the first 12 months of elCID use, the haematology service generated 3674 clinical reviews from which clinical advice was offered on 1490 occasions. The clinical reviews also resulted in 799 antimicrobial prescription changes and infection control advice being offered directly during these ward rounds on 362 occasions. These figures are in sharp contrast to attempts to derive such information pre-elCID, namely a timeconsuming, manual review of a limited subset of T-cards and subsequent extrapolation from a potentially unrepresentative and biased sample. In addition to the benefits of improved data capture, the system has improved provision
of care for this patient cohort. By definition, the previous T-Card based system relied on single user, physical data capture that limited real-time collaborative reviews and clinical input into the care of patients. The switch to elCID has allowed faster, more detailed recording of clinical interactions that are remotely and contemporaneously accessible to clinicians in both microbiology and haematology departments.
Case study 3: integrated clinical research platform The modular nature of elCID allows research data to be collected alongside routine clinical data, reducing the need for additional research specific databases. Userspecific access rights allow additional components of the database to be restricted to clinicians and academics participating in studies whilst simultaneously linking this research data to patients’ underlying routine clinical data. As data are captured prospectively in a coded format, the system provides a platform to identify
Letters to the Editor individuals meeting specified criteria and trigger referral to research nurses or additional data collection. Utilisation of such functionality helps to bridge gaps between provision of clinical care and participation in research, and has specifically been exploited by the Rapid Identification of Respiratory Tract Infection (RiD-RTI) European FP7 project that utilises elCID to both identify eligible patients for the study, as well as anonymously process and record research data collection.9
Conclusions Fragmented data presents a barrier to high quality patient care, service evaluation and research. The development of elCID has resulted in an integrated platform to address these key unmet needs, and its utilisation has provided a platform to both drive clinical service delivery and undertake audit and research. Adoption of elCID, or development of similar solutions, to record clinical activity should be considered widely across other Trusts in the UK with similar visions for data-driven improvement in quality and care delivery.
Funding This work is supported by NIHR Biomedical Research Centre funding to UCLH and UCL, and by Wellcome Trust Clinical Research Fellowships to MM (WT102807) and GP (WT101766). The funding agencies had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflict of interest DM and CR are employees of Open Health Care UK (OHCUK), the company that designed elCID. The other authors have no financial relationship with OHCUK.
References 1. King C, Aylin P, Moore LSP, Pavlu J, Holmes A. Syndromic surveillance of surgical site infectionsea case study in coronary artery bypass graft patients. J Infect 2014;68:23e31. 2. Petrak Russell M, Sexton Daniel J, Butera Michael L, Tenenbaum Marvin J, MacGregor Mary C, Schmidt Mary E, et al. The value of an infectious diseases specialist. Clin Infect Dis Off Publ Infect Dis Soc Am 2003;36(8):1013e7. http: //dx.doi.org/10.1086/374245. 3. Bursle EC, Playford EG, Looke DFM. Infectious diseases consultations at an Australian tertiary hospital: a review of 11,511 inpatient consultations. Intern. Med J 2014;44: 998e1004. 4. Vehreschild JJ, Morgen G, Cornely OA, Hartmann P, Koch S, Kalka-Moll W, et al. Evaluation of an infectious disease consultation programme in a German tertiary care hospital. Infection 2013;41(6):1121e8. http://dx.doi.org/10.1007/s15010-0130512-1. 5. Schmitt Steven, McQuillenDaniel P, Nahass Ronald, Martinelli Lawrence, Rubin Michael, Schwebke Kay, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs. Clin Infect
405
6.
7.
8. 9.
Dis Off Publ Infect Dis Soc Am 2014;58(1):22e8. http: //dx.doi.org/10.1093/cid/cit610. Sharma R, Loomis W, Brown RB. Impact of mandatory inpatient infectious disease consultation on outpatient parenteral antibiotic therapy. Am J Med Sci 2005;330:60e4. De Lusignan S, Hague N, van Vlymen J, Kumarapeli P. Routinely-collected general practice data are complex, but with systematic processing can be used for quality improvement and research. Inf Prim Care 2006;14:59e66. Electronic clinical infection database (elCID). at . RiD-RTI Rapid identification of respiratory tract infections. at .
Michael Marks1 Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK The Hospital for Tropical Diseases, Mortimer Market Centre, Mortimer Market, Capper Street, London, UK Gabriele Pollara1 Department of Microbiology, University College London Hospital, 235 Euston Road, London, UK Division of Infection and Immunity, University College London, Cruciform Building, Gower Street, London, UK David Miller Open Health Care UK, Unit 3 127 Stoke Newington Road, London, UK Sonia Bhatt Department of Microbiology, University College London Hospital, 235 Euston Road, London, UK Carl Reynolds Open Health Care UK, Unit 3 127 Stoke Newington Road, London, UK Vanya Gant Department of Microbiology, University College London Hospital, 235 Euston Road, London, UK Mahdad Noursadeghi* Division of Infection and Immunity, University College London, Cruciform Building, Gower Street, London, UK *Corresponding author. Division of Infection and Immunity, University College London, Cruciform Building, Gower Street, London, UK.
E-mail address: [email protected] (M. Noursadeghi) Accepted 10 April 2015 http://dx.doi.org/10.1016/j.jinf.2015.04.007 ª 2015 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
1 Michael Marks and Gabriele Pollara contributed equally to this manuscript.
