Updates in Hospital Medicine 2013
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Transcript of Updates in Hospital Medicine 2013
Updates in Hospital Medicine2013
Kendall Rogers, MD CPE FACP SFHMAssociate Professor and ChiefDivision of Hospital Medicine
University of New Mexico School of Medicine
Disclosures
No disclosures to report.
Acknowledgements
• Michelle Mourad• Hospital Medicine Journal Club• Anthony Worsham, Sheila Modi, and Jens
Langsjoen
Updates in Hospital Medicine 2013
Updates in Hospital Medicine 2013• Articles From Late 2012 and
2013
Process:• Reviewed and stole from SHM
Update in Hospital Medicine 2013
• Reviewed all articles presented at Division of Hospital Medicine Journal Club
• CME collaborative review of journals
▪ Including ACP J. Club, J. Watch, etc.
• 1 in 5 hospitalized patients get a foley, up to half are inappropriate
• 26% will develop bacteriuria, and 24% of those will develop CAUTI
• 13,000 deaths per year to CAUTI• Annual direct medical costs between $340 to
$370 million
• As many as 71% of hospitalized patients on GI prophylaxis without indication
• Strong correlation between PPI use and pneumonia and C. Diff infections
• PPI not recommended for adult patients in non-ICU settings with fewer than 2 risk factors for bleeding
• A restrictive approach with Hgb cutoff of 7 g/dL has shown improved outcomes
• Holds true to AMI, GI bleed, and surgical patients
• Cost of blood $700-900 per unit and carries infectious and noninfectious adverse reactions
• Study showed only 12.6% of patients on non-ICU required telemetry and only 7% received modified management due to telemetry
• Telemetry – Is resource intensive – Does not alter management – Can lead to additional testing – Increased length of stay in ED– Reduced hospital throughput – A false sense of security
• Studies show no difference in readmit rates, transfers to ICU, LOS, rates of adverse events, or mortality when frequency reduced
• Charges estimated at $150/patient/day• Hospital acquired anemia shown to have
worse outcomes
What didn’t make it on SHM:
• Don’t presume a patient to be full code on admission, have a code status discussion with all patients to confirm.
OTHER CHOOSING WISELY LISTS PERTINENT TO HOSPITAL MEDICINE
Other Choosing Wisely Lists:• ACP
– In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI)
– In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
– Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
Other Choosing Wisely Lists:
• Palliative Medicine– Don’t recommend percutaneous feeding tubes in
patients with advanced dementia; instead, offer oral assisted feeding.
– Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
– Don't leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.
Other Choosing Wisely Lists:
• Neuro– Don’t perform imaging of the carotid arteries for
simple syncope without other neurologic symptoms.
• GI– For pharmacological treatment of patients with
gastroesophageal reflux disease (GERD), long term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
Other Choosing Wisely Lists:
• Radiology– Don’t image for suspected pulmonary embolism
(PE) without moderate or high pre-test probability.
– Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
Other Choosing Wisely Lists:• Geriatrics
– Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
– Avoid using medications to achieve hemoglobin A1c<7.5% in most adults age 65 and older; moderate control is generally better.
– Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.
– Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Other Choosing Wisely Lists:
• Echocardiography– Avoid transesophageal echocardiography (TEE) to
detect cardiac sources of embolization if a source has been identified and patient management will not change.
• Nuclear Cardiology– Don't perform cardiac imaging as a pre-operative
assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.
Other Choosing Wisely Lists:
• Nephrology– Avoid nonsteroidal anti-inflammatory drugs
(NSAIDs) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.
• Nuclear Medicine– Avoid using a computed tomography angiogram
to diagnose pulmonary embolism in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead.
Other Choosing Wisely Lists:
• Vascular Medicine– Don’t do work up for clotting disorder (order
hypercoagulable testing) for patients who develop first episode of deep vein thrombosis (DVT) in the setting of a known cause.
– Don’t reimage DVT in the absence of a clinical change.
– Avoid cardiovascular testing for patients undergoing low-risk surgery.
NOW ON WITH THE CASES!
Case 1
76 y.o. patient with COPD, chronic venous insufficiency, previous C. difficile. One day history of fever, chills…
Pulse 120BP 94/60T 102.4RR 28
WBC 18,000 with 18% bandsLactate 3
Is there another symptom or sign that helps predict bacteremia?
Predicting bacteremia based on nurse-assessed food consumption at the time of blood culture.
Komatsu T et al. J Hosp Med 2012; 7:702-205
Exclude: Other causes of decreased oral intake
True positive cultures well-defined
Patients meeting entry criteria
n = 1179
Patients meeting entry criteria
n = 1179
IVH/NPO, n=194N/G tube feeding, n=134
IVH/NPO, n=194N/G tube feeding, n=134
Blood Culture –n = 729
Blood Culture –n = 729
True Positiven = 75
True Positiven = 75
n = 851n = 851
Blood Culture +n = 122
Blood Culture +n = 122
Komatsu T et al. J Hosp Med 2012; 7:702-205
Category Definition N Positive cultures % positive
Low <50% food consumed
Moderate 50-80% food consumed
High >80% food consumed
Komatsu T et al. J Hosp Med 2012; 7:702-205
Category Definition N Positive cultures % positive
Low <50% food consumed
344 63 18%
Moderate 50-80% food consumed
152 6 4%
High >80% food consumed
354 6 1.7%
The Case continues…..
Blood cultures: MRSA Blood cultures: MRSA
48 hours into hospitalization: Still febrile, BPs labile and lowish48 hours into hospitalization: Still febrile, BPs labile and lowish
+
Is daptomycin better than vancomycin for MRSA
bacteremia?
Daptomycin versus vancomycin for bloodstream infections due to methicillin-resistant Staphylococcus aureus with a high vancomycin minimum inhibitory concentration: a case-control study.
Design:
Moore CL et al. Clin Infect Dis 2012; 54:51-8.
Single center, retrospectiveSingle center, retrospective
MRSA blood culture isolates with vancomycin minimum inhibitory concentration less than or
equal to 2
MRSA blood culture isolates with vancomycin minimum inhibitory concentration less than or
equal to 2
Moore CL et al. Clin Infect Dis 2012; 54:51-8.
Outcome Vancomycin (n = 118)
Daptomycin (n = 59) P
Clinical failure
60-day mortality
Microbiologic failure
Recurrence of MRSA bloodstream infection
Moore CL et al. Clin Infect Dis 2012; 54:51-8.
Outcome Vancomycin (n = 118)
Daptomycin (n = 59) P
Clinical failure 37 (31%) 10 (17%) .084
60-day mortality 24 (20%) 5 (8%) .046
Microbiologic failure
11 (9%) 6 (10%) .855
Recurrence of MRSA bloodstream infection
6 (5%) 2 (3%) .620
On with the case!Our patient is treated and discharged but then returns to the ED increased cough and SOB. Initially on BiPAP, now on NC.
His labs are only notable for a BUN of 35 and a creatinine of 1.9. He has diffuse loud wheezes on exam and is difficult to arouse.
AfebrileBP: 135/85Pulse: 110O2 sat: 94% on 4L NC
AfebrileBP: 135/85Pulse: 110O2 sat: 94% on 4L NC
Case Presentation
“The patient has a monitored floor bed upstairs and is just waiting for your admitting orders.”
Where do you think the patient should be admitted?
A. Need an ABG before triage to the floor
B. Regular floor on telemetry
C. His age, pulse, BUN and altered mental status identify risk for bad outcomes on the floor
D. Needs the ICU
E. Sounds like an “obs” patient to me
Is there an easy risk score that can predict poor outcomes in
acute COPD?
Validation of a Novel Risk Score for Severity of Illness in Acute Exacerbations of COPD
Design:
Validation of a risk score for pts with acute COPD admitted to hospital, retrospective cohort
Shorr AF, et al. Chest. 2011;140(5):1177-1183.
34,699 patients > 40 years old, acute exacerbations of COPD. Ability of the BAP-65 score to predict outcomes, LOS and cost.
B – BUN >25 A – AMS P – Pulse >109 >65 year old
B – BUN >25 A – AMS P – Pulse >109 >65 year old
BAP-65 score for COPD risk
Shorr AF, et al. Chest. 2011;140(5):1177-1183.
B – BUN >25 A – AMS P – Pulse >109 >65 year oldB – BUN >25 A – AMS P – Pulse >109 >65 year old
Conclusion: BAP-65 can be useful in initial triage to predict MV and mortality. Better at identifying patients with low risk, who are safe for floor.
Comment: Measurements all present on an initial assessment, but may leave out other key information that could improve triage.
BAP-65 score for COPD risk
Shorr AF, et al. Chest. 2011;140(5):1177-1183.
Where do you think the patient should be admitted?
A. Need an ABG before triage to the floor
B. Regular floor on telemetry
C. His age, pulse, BUN and altered mental status identify risk for bad outcomes on the floor
D. Needs the ICU
E. Sounds like an “obs” patient to me
Where do you think the patient should be admitted?
A. Need an ABG before triage to the floor
B. Regular floor on telemetry
C. His age, pulse, BUN and altered mental status identify risk for bad outcomes on the floor
D. Needs the ICU
E. Sounds like an “obs” patient to me
Our case continues...
We start prednisone, Azithromycin and admit him to the ICU, where he is intubated for 2 days due to progressive hypercarbia and extubated on hospital day #3 and he is moved to the floor.
Two days later his WBC rises to 24, and we are a little worried this isn’t just the steroids.
Nurse states pt having loose stools that smell like C. Diff
Should you believe her? Can you tell C. Difficile simply by its smell ?
Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and
patients: proof of principle study
• Beagle trained to identify the smell of C.difficile in stool samples and sit or lie down with a positive result. • Performance was tested on 100 stool samples & 300 patients (30 cases and 270 controls).
Bomers, MK et al. BMJ; 2012:345, 7-9
Test Sensitivity Specificity Speed Cost
Glutamate dehydrogenase (GDH) 70-80% <90% Hours $17
EIA (Toxin A and B) 60-80% 75-99% Hours $5-17
PCR (toxin B) >90% >95% Hours $20-50
Stool cytotoxin of cell culture 70-80% >97% 2 to >3d $7-13
Culture for C. difficile >90% 95-97% 2 to >3d $10-22
Bomers, MK et al. BMJ; 2012:345, 7-9
Test Sensitivity Specificity Speed Cost
Glutamate dehydrogenase (GDH) 70-80% <90% Hours $17
EIA (Toxin A and B) 60-80% 75-99% Hours $5-17
PCR (toxin B) >90% >95% Hours $20-50
Stool cytotoxin of cell culture 70-80% >97% 2 to >3d $7-13
Culture for C. difficile >90% 95-97% 2 to >3d $10-22
Nursing Staff 55-82% 77-83% Minutes free
Bomers, MK et al. BMJ; 2012:345, 7-9
Test Sensitivity Specificity Speed Cost
Glutamate dehydrogenase (GDH) 70-80% <90% Hours $17
EIA (Toxin A and B) 60-80% 75-99% Hours $5-17
PCR (toxin B) >90% >95% Hours $20-50
Stool cytotoxin of cell culture 70-80% >97% 2 to >3d $7-13
Culture for C. difficile >90% 95-97% 2 to >3d $10-22
Nursing Staff 55-82% 77-83% Minutes free
C. Diff Beagle (stool samples) 100% 100% Minutes 2 month training
C. Diff Beagle (person) 83% 98% Minutes 2 month training
Take home points: Cute, low cost, cute alternative to laboratory testing with similar sensitivity and specificity to commonly available tests. Bomers, MK et al. BMJ; 2012:345, 7-9
Our case continues...
The nurse asks if the patient had been on probiotics, would that have prevented this episode of C. Diff?
Probiotics
• Meta-analysis of 23 trials (4213 participants)• Many different strains and doses• Suggests that probiotics decrease CDAD by
64%• Incidence of 2.0% with probiotics and 5.5%
without• ‘Moderate’ confidence probiotics decreases
CDAD
• Hospitalists This well done meta-analysis supports the contention that probiotics can help prevent C. difficile-associated diarrhea, although they do not appear to affect the rate of C. difficile infection itself. The dose, preparation, and timing of probiotics, however, remains unclear as well as which patients would most benefit from this prophylactic therapy.
BUT WAIT!
• Lancet. 2013 Aug 7. doi:pii: S0140-6736(13)61218-0. 10.1016/S0140-6736(13)61218-0. [Epub ahead of print]. PMID: 23932219
• Study design– Multicenter double blind RCT (2900 participants)
• Population– 65yo inpatients on abx within past 7 days.
• Intervention (vs placebo)– L. acidophilus, B. bifidum, B. Lactis, 1-60b cfu
• Outcomes– AAD or CDAD
Good parts of study design
• Blinding: good• Randomization: good• Intervention: dosing was good (billions)…
Problems with study design• They selected for patients that don’t get AAD
– Pts on abx during last 7 days without diarrhea on admission
– 7 day ‘grace period’ catches many patients on tail end of abx therapy
– Patients already with AAD all excluded– Study incidence of AAD 10% (should be 20-30%)
• C diff incidence was too low– C diff incidence 1% (predicted 4%)– % of AAD that was 2/2 C diff
• 7%, usually closer to 25%– Only 57% of AAD events sent for c diff testing
Problems with study design
• Poor compliance (50% in both groups)• Unknown % already on probiotics (>5%)
– but 200 (>3%) excluded for refusing to stop probiotic
• Lactobacillus acidophilus
Wrong strains?• Lactobacillus acidophilus and Bifidobacterium
– No good trials on L. acidophilus– Similar mixtures: 3 small (n<100) trials, small effect
• McFarland meta-analysis- Only L. Rhamnosus GG, S. Boulardii and probiotic
mixtures were effective on subgroup analyses
• Johnston meta-analysis Only LGG, L Coagulans, and S. Boulardii effective in
subgroups
Our patient asks about the effectiveness of stool transplant for curing C. difficile infection.
What is the effectiveness of fecal bacteriotherapy (i.e. stool transplant)
in the management of C. difficile?
Systematic Review of Intestinal Microbiota Transplantation (Fecal Bacteriotherapy) for Recurrent
Clostridium difficile Infection
Design: Systematic review
• 27 articles involving 317 patients• No RCT in this systematic review• All patients had a diagnosis of
recurrent or relapsing CDI
• 27 articles involving 317 patients• No RCT in this systematic review• All patients had a diagnosis of
recurrent or relapsing CDI
Gough, E et al. CID; 2012: 53, 994-1002
Effectiveness of fecal bacteriotherapy
Treatment Cure Rates Recurrence Rates
Cost for 10 day tx(cost per tablet)
Metronidazole 73-94% 5-25% $21 ($0.67)
Vancomycin 84-94% 7-25% $1,280 ($32)
Fidaxomycin 80-90% 15% $2700 ($135)
Gough, E et al. CID; 2012: 53, 994-1002
Effectiveness of fecal bacteriotherapy
Treatment Cure Rates Recurrence Rates
Cost for 10 day tx(cost per tablet)
Metronidazole 73-94% 5-25% $21 ($0.67)
Vancomycin 84-94% 7-25% $1,280 ($32)
Fidaxomycin 80-90% 15% $2700 ($135)
Stool transplant 88-92% 4% ~$1500
• Nearly all (92%) experienced resolution, most (88%) after only 1 treatment.
• Related donors better than unrelated, enema better than upper GI tract, and larger volumes of stool were better than lower volumes.
• Side effects of stool transplantation were rare and relapse of C. difficile after treatment was rare. Gough, E et al. CID; 2012: 53, 994-1002
Take home pointsStart:
–Questioning bacteremia when hamburger sign +–Referring those with relapsing C.difficile for stool transplant–A beagle training camp in Albuquerque to C. Diff detection
Consider:– Daptomycin in MRSA infection with vancomycin MIC ≥2– BAP-65 of 0 to identify low risk patients – Probiotics in patient on antibiotics to prevent C. Diff
Stop:•Doing everything on the Choosing Wisely Lists
Case 2
65 y.o. patient with early Parkinson’s Disease presents with four hours of shortness of breath and chest pain.
BP 140/80, P 96, T 37.9, RR 22, SaO2 92%
Exam: RV heave, increased P2
WBC 11,300
NT-proBNP 1568
D-dimer 3560
The case continues…
Blood pressure falling, oxygen requirement increasing…
Thrombolytics?
Thrombolytic therapy in unstable patients with acute pulmonary embolism: Saves lives but underused.
Design:Retrospective database analysis
1999-2008 Nationwide Inpatient Sample
Stein PD and Matta F. Am J Med 2012; 125:465-470
2 million patients with PE
72,230 patients with unstable PE
21,390 (30%) received thrombolytics
Mortality attributable to PE
Stein PD and Matta F. Am J Med 2012; 125:465-470
Figure 3. In hospital death attributable to pulmonary embolism in unstable patients with pulmonary embolism. All unstable patients (left), Unstable patients who received a vena cava filter (right). Differences of case fatality rate, P <0.001. PE – pulmonary embolism; VC – vena cava
Case continues…..
The patient undergoes successful thrombolysis, placement of an IVC filter, and is being managed with enoxaparin SC. Warfarin is initiated.
“But wait a minute, this patient is at risk for falls. Can we safely use warfarin?”
Risk of falls and major bleeds in patients on oral anticoagulation therapy
Donze J et al. Am J Med 2012; 125:773-778.
Design:
Definition of high risk:Prospectice cohort study, 515 patientsProspectice cohort study, 515 patients
If patients answered yes to either of the following questions:•Did you fall during the past year? •If not, then, Did you notice any problem with gait, balance, or mobility?
If patients answered yes to either of the following questions:•Did you fall during the past year? •If not, then, Did you notice any problem with gait, balance, or mobility?
Donze J et al. Am J Med 2012; 125:773-778.
Outcome High fall risk (n=308)
Low fall risk (n=207)
Notes
Crude incidence of major bleeds
Gastrointestinal bleeds
Intracerebral bleeds
Fatal bleed
Bleed in context of INR > 3.0
Fall-related bleed
Donze J et al. Am J Med 2012; 125:773-778.
Outcome High fall risk (n=308)
Low fall risk (n=207)
Notes
Crude incidence of major bleeds
8.0 per 100 patient years
6.8 per 100 patient years
P = 0.64
Gastrointestinal bleeds 11 events 2 events
Intracerebral bleeds 2 events 4 events
Fatal bleed 3 events 2 events
Bleed in context of INR > 3.0
8 events 1 events
Fall-related bleed 1 event 2 events All nonfatal subdural hematomas
Case continues…..
The patient does well. INR on warfarin 2.5. Ready for discharge. As we prepare the discharge summary, we note that the platelet count on admission was 230,000 then 3 days into the course was 130,000 and stabilized at that level.
Should we worry?
Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and
meta-analysis
Cuker A et al. Blood 2012; 120: 4160-4167
4Ts category 2 points 1 point 0 points
ThrombocytopeniaPlatelet count fall > 50% and platelet nadir ≥ 20
Platelet count 30%-50% or platelet nadir 10-19
Platelet count fall < 30% or platelet nadir < 10
Timing of platelet count fall
Clear onset days 5-10 or platelet fall ≤ 1 day (prior heparin exposure within 30 days)
Consistent with days 5-10 fall, but not clear (eg, missing platelet counts); onset after day 10; or fall ≤ 1 day (prior heparin exposure 30-100 days ago)
Platelet count ≤ 4 days without recent exposure
Thrombosis or other sequelae
New thrombosis (confirmed); skin necrosis; acute systemic reaction postintravenous unfractionated heparin bolus
Progressive or recurrent thrombosis; non-necrotizing (erythematous) skin lesions; suspected thrombosis (not proven) None
Other causes of thrombocytopenia None apparent Possible Definite
Table 1. The 4Ts scoring system for HIT
Cuker A et al. Blood 2012; 120: 4160-4167
Category Score HIT+/total (%) Predictive value (95% CI)
High 6-8 points 128/253 (50.5%) Positive PV 0.64, (0.40-0.82)
Intermediate 4-5 points 148/1251 (11.8%) Positive PV 0.14 (0.09-0.22)
Low 1-3 points 13/1712 (0.8%) Negative PV 0.998 (0.97-1.00)
Case continues…..
Six months later the patient is admitted for an unrelated problem. She wonders…..
Design:
Aspirin for preventing the recurrence of venous thromboembolism
Treated with at least 6months with oral anticoagulation
Becattini C et al. N Engl J Med 2012; 366:1959-1967.
Multicenter RCTMulticenter RCT
403 patients with first unprovoked VTE
403 patients with first unprovoked VTE
ASA 100mg ASA 100mg PlaceboPlacebo
Becattini C et al. N Engl J Med 2012; 366:1959-1967.
Outcome Aspirin (n=205)
Placebo (n=197)
Hazard ratio (95% CI) P value
Recurrent VTE 28 43 0.58 (0.36-0.93) 0.02
Pulmonary embolism 11 14 0.70
(0.32-1.54) 0.37
Fatal PE 1 1
Bleeding 4 4 0.98 (0.24-3.96) 0.97
Major bleeding 1 1
Death 6 5 1.04 (0.32-3.42) 0.95
Arterial event 8 5 1.43 (0.47-4.37) 0.53
On with the case!
Several weeks later walking through the ED we notice our patient lying on a gurney.
She’s been feeling nauseated for days and throwing up coffee grounds.
Her hct drops steadily She develops melena…
What is the optimal transfusion threshold for
patients with acute UGIB?
Transfusion Strategies for Acute Upper Gastrointestinal Bleeding
Design:
All patients received 1 unit PRBCs prior to Hgb measurement and prompt endoscopy within 6 hours
921 patients with severe acute upper GI bleed
Single site, non-blinded study, included those with suspected liver disease and potential variceal bleeding
Transfusion for target Hgb 7
Transfusion for target Hgb 10
Villanueva C et al. N Engl J Med 2013; 368: 11-21.
Results:
•Survival at 6 weeks was significantly higher in the restrictive target group compared to the liberal target.
Optimal Transfusion in UGIB
Transfusion for target Hgb 7
95% Survival
Transfusion for target Hgb 10
91% Survival10% Rebleeding 16% Rebleeding
Villanueva C et al. N Engl J Med 2013; 368: 11-21.
Conclusion: In HD stable patients with acute UGIB (even variceal), a target Hgb of 7 is associated with better outcomes.
Comment: Did not apply to exsanguinating patients or those in shock. Patients also received endoscopy in 6 hours for a possible intervention.
Optimal transfusion in UGIB
Villanueva C et al. N Engl J Med 2013; 368: 11-21.
Our case continues...We decide to hold off on transfusion.
Endoscopy demonstrates several small, clean-based, shallow peptic ulcer, most likely from her recent aspirin use.
• Extendend prophylaxis for 28 days with aspirin was noninferior to and as safe as dalteparin for the prevention of VTE after THA in patients who initially received dalteparin for 10 days.
Take home pointsStart:•Using thrombolytics in patients with unstable PE
Stop:•Witholding warfarin in patients with a fall risk•Transfusing patients with an UGIB and a Hbg >7
Consider:•Using a low 4T’s score to rule out HIT• Using aspirin after 10 days of LMWH