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Update in Hospital Medicine 2017-2018

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Update in Hospital Medicine 2017-2018 Update in Hospital Medicine 2017-2018 VS. Brad Sharpe, MD SFHM Update in Hospital Medicine Year in Review 2017-2018 Year in Review 2017-2018 • Updated literature Chose articles based on 3 criteria: • March 2017* – March 2018 1) Change your practice Process: 2) Modify your practice 3) Confirm your practice • CME collaborative review of journals ▪ Including ACP J. Club, J. Watch, etc. • Hope to not use the words: • Independent analysis of article quality • Student’s t-test, meta-regression, Mantel-Haenszel statistical method, etc. • Thank you to Brad Monash, Alfred Burger, • Focus on breadth, not depth Cynthia Cooper, Barbara Slawski Year in Review Year in Review Year in Review 2017-2018 Syllabus/Bookkeeping • Major reviews/short takes • No conflicts of interest • Case-based format • Final presentation • Multiple choice questions available by email: • Promote retention [email protected] Year in Review Year in Review Case Presentation You are the attending and hearing about a holdover admission from the nightfloat. She describes an 83 year-old woman with a history of chronic obstructive pulmonary disease (COPD) who presented with two days of shortness of breath and subjective fevers and then an acute syncopal episode. She described mild shortness of breath and fevers and chills and then syncopized when walking to the bathroom at home. Year in Review Year in Review Case Presentation Case Presentation On examination, she was febrile, tachycardic, and For the antibiotics, she says she has started hypoxic (86% on room air, 96% on 4 liters). ceftriaxone and doxycycline and will plan on She had crackles at the right base and diffuse treating for a total of 5 days. wheezing and was alert and oriented. She asks you, “For community-acquired Her white blood cell count was elevated and her pneumonia (CAP), do you think five days is chest x-ray showed a right lower lobe infiltrate. enough for most patients?” The nightfloat states she thinks this is community-acquired pneumonia and a COPD How do you respond to her question about the exacerbation and describes her plan for duration of antibiotics for community-acquired antibiotics, corticosteroids, and bronchodilators. pneumonia? Update in Hospital Medicine Update in Hospital Medicine How do you respond to her question Treatment Duration for CAP about the treatment duration for CAP? Question: What is the optimal duration of antibiotics in patients hospitalized with CAP? A. Usually it is just 3 days. Design: Randomized, controlled; non-blinded, non- B. We usually do 5 days. inferiority trial Hospitalized for CAP, age > 18 years-old C. Most of the time it is 7 days. • All patients treated for 5 days D. Guidelines recommend 10 days. • Randomized to stopping vs. continuing antibiotics E. Typically we do a full 14 days. Stop Continue • No fever for 48o • Duration determined F. Do you think five days is enough? • 0-1 abnormal vitals by MD Update in Hospital Medicine Uranga A, et al. JAMA Int Med.2016;176:1257. Update in Hospital Medicine Results Results • A total of 312 patients, ~40% women, non-ICU • A total of 312 patients, ~40% women, non-ICU • Most received a fluoroquinolone (~80%) • Most received a fluoroquinolone (~80%) Outcome 5 Days Longer p Outcome 5 Days Longer p Clinical Success (10d) Clinical Success (10d) 56.3% 48.6% 0.18 Clinical Success (30d) Clinical Success (30d) Mortality (30d) Mortality (30d) Median Duration of Abx Median Duration of Abx Uranga A, et al. JAMA Int Med.2016;176:1257 Update in Hospital Medicine Uranga A, et al. JAMA Int Med.2016;176:1257 Update in Hospital Medicine Results Results • A total of 312 patients, ~40% women, non-ICU • A total of 312 patients, ~40% women, non-ICU • Most received a fluoroquinolone (~80%) • Most received a fluoroquinolone (~80%) Outcome 5 Days Longer p Outcome 5 Days Longer p Clinical Success (10d) 56.3% 48.6% 0.18 Clinical Success (10d) 56.3% 48.6% 0.18 Clinical Success (30d) 91.9% 88.6% 0.33 Clinical Success (30d) 91.9% 88.6% 0.33 Mortality (30d) Mortality (30d) 2.1% 2.2% 0.99 Median Duration of Abx Median Duration of Abx Uranga A, et al. JAMA Int Med.2016;176:1257 Update in Hospital Medicine Uranga A, et al. JAMA Int Med.2016;176:1257 Update in Hospital Medicine Results Treatment Duration for CAP • A total of 312 patients, ~40% women, non-ICU Question: What is the optimal duration of antibiotics in • Most received a fluoroquinolone (~80%) patients hospitalized with CAP? Design: Randomized, controlled; non-blinded; non- Outcome 5 Days Longer p inferiority trial Hosp. for CAP, age > 18 yo Clinical Success (10d) 56.3% 48.6% 0.18 Conclusion: In CAP, if afebrile x 48o & stable vitals, 5 days Clinical Success (30d) 91.9% 88.6% 0.33 non-inferior to longer course; No diff. in clinical outcomes; Less antibiotics Mortality (30d) 2.1% 2.2% 0.99 Comments: Well done RCT, generalizability? Median Duration of Abx 5 days 10 days 0.001 Confirms prior studies/guidelines For most patients, 5 days is enough • A total of ~70% got 5 days in the intervention group • No difference for sicker patients Use your judgement, can treat longer • Readmissions at 30 days lower in shorter-course Update in Hospital Medicine Uranga A, et al. JAMA Int Med.2016;176:1257. Update in Hospital Medicine How do you respond to her question How do you respond to her question about the treatment duration for CAP? about the treatment duration for CAP? A. Usually it is just 3 days. A. Usually it is just 3 days. B. We usually do 5 days. B. We usually do 5 days. C. Most of the time it is 7 days. C. Most of the time it is 7 days. D. Guidelines recommend 10 days. D. Guidelines recommend 10 days. E. Typically we do a full 14 days. E. Typically we do a full 14 days. F. Do you think five days is enough? F. Do you think five days is enough? Update in Hospital Medicine Update in Hospital Medicine Case Presentation Case Presentation You both agree that it likely will be 5 days but will depend on how the patient responds to treatment. The nightfloat finishes her presentation and you ask, “What did you think about the syncope?” She pauses, rubs her chin, and says, “Well, I think it is probably orthostasis but she is short of breath. Do you think we need to worry about PE as a cause for her syncope?” Year in Review Year in Review Short Take: PE in Syncope Case Presentation • One meta-analysis and two retrospective studies You respond that we probably don’t need to think about PE in this case given this was likely • Prevalence of PE in the setting of syncope is orthostatic hypotension based on the history. probably: 1-2% You ask if orthostatics were performed before she • Multiple flaws with the prior study received intravenous fluids. The nightfloat says they were “borderline” positive. • Consider PE as a cause for syncope She asks, “Can you clarify how we’re supposed to • A routine evaluation for PE in syncope is do orthostatics? I have heard different things not warranted about how long you have to wait after the patient stands up.” Oqab Z, et al. Am J Emerg Med. Sept 2017. Costantino G, et al. JAMA Int Med. March 2018. Year in Review Year in Review Epstein D, et al. PLoS One. March 2018. Short Take: Orthostatic Vital Signs Case Presentation • Prospective cohort study of 11,429 middle-aged You make this teaching point and the nightfloat adults (age 44-66 years) finishes and leaves to get some sleep. • Orthostatic vital signs were checked every 30 Later that day, you have a chance to review more seconds of the patient’s history and see that she has a • Orthostatic hypotension within one minute of history of C diff infection. standing was most strongly associated with: She was in the hospital two weeks prior on broad- -- Dizziness -- Falls spectrum antibiotics for pyelonephritis and is on -- Fracture -- Syncope acid suppression. -- Car crashes -- Death Based on this, you feel like she is at very high risk for C diff as she is now hospitalized on Juraschek SP, et al. JAMA Intern Med.2017;177:1316. antibiotics. Update in Hospital Medicine What can you do to prevent the development Probiotics for C diff. of C diff during this hospital stay? Question: What is the role for probiotics in the prevention of C difficile infection? A. Wash your hands with hand gel. Design: Syst. review & meta-analysis of B. Use your own stethoscope but wash it randomized, controlled trials with the little alcohol swab. Probiotics vs. other to prevent C diff. C. Start probiotics. • Included any strain (16 types) & any dose of probiotic D. Start empiric fidaxomicin. • Some risk of bias in some studies E. Donate some of your own stool for a fecal transplant. Update in Hospital Medicine Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. Update in Hospital Medicine Probiotics for C. difficile Probiotics for C. difficile • A total of 31 trials, 8672 patients • A total of 31 trials, 8672 patients Outcome Probiotics Other p Outcome Probiotics Other p All Patients All Patients 1.5% 4.0% <0.05* Baseline Risk Risk Ratio p 0-2% 3-5% > 5% Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. * MODERATE Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. * MODERATE Probiotics for C. difficile Probiotics for C. difficile • A total of 31 trials, 8672 patients • A total of 31 trials, 8672 patients Outcome Probiotics Other p Outcome Probiotics Other p All Patients 1.5% 4.0% <0.05* All Patients 1.5% 4.0% <0.05* Baseline Risk Risk Ratio p Baseline Risk Risk Ratio p 0-2% 0.77 NS > 5% 0.30 <0.01* (3.1% v 11.6%) 3-5% 0.53 NS • Antibiotic-associated diarrhea less in probiotics group > 5% 0.30 <0.01 (3.1% v 11.6%) • Adverse events lower in probiotics group • Detection of C diff in the stool was the same • No difference with different probiotics Goldenberg JZ, et al.
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