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.


• 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.


• 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.


• 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.


• 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.


• 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


Category Definition N Positive cultures % positive

Low <50% food consumed

Moderate 50-80% food consumed

High >80% food consumed


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


Outcome Vancomycin (n = 118)

Daptomycin (n = 59) P

Clinical failure

60-day mortality

Microbiologic failure

Recurrence of MRSA bloodstream infection


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


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






D. Needs the ICU






D. Needs the ICU


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





PCR (toxin B) >90% >95% Hours $20-50



Nursing Staff 55-82% 77-83% Minutes free





PCR (toxin B) >90% >95% Hours $20-50



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?


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


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


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


95% Survival


91% Survival10% Rebleeding 16% Rebleeding


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


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

Documents

Updates in Hospital Medicine 2013