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Update in Hospital Medicine 2011

Update in Hospital Medicine 2011. Michael Hwa, MD Assistant Clinical Professor UCSF Division of Hospital Medicine. Update in Hospital Medicine 2011. Brad Sharpe, MD Associate Chief. Michelle Mourad, MD Director of DHM Quality. Update in Hospital Medicine. VS.

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Update in Hospital Medicine 2011

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  1. Update in Hospital Medicine 2011 Michael Hwa, MD Assistant Clinical Professor UCSF Division of Hospital Medicine

  2. Update in Hospital Medicine 2011 Brad Sharpe, MD Associate Chief Michelle Mourad, MD Director of DHM Quality Update in Hospital Medicine Update in Hospital Medicine

  3. VS. Update in Hospital Medicine

  4. Update in Hospital Medicine 2011 • Updated literature since Summer 2010 • Process: • Collaborative review of journals • ▪ Including ACP J. Club, J. Watch, etc. • Three hospitalists ranked articles • ▪ Definitely include, can include, don’t include Update in Hospital Medicine Update in Hospital Medicine

  5. Update in Hospital Medicine 2011 • Chose articles based on 3 criteria: • Change your practice • Modify your practice • Confirm your practice • Hope to not use the words • ▪ Markov model, Kaplan-Meier, Student’s t-test • Focus on breadth, not depth Update in Hospital Medicine Update in Hospital Medicine

  6. Update in Hospital Medicine 2011 • Major reviews/short takes • Case-based format, multiple choice ?’s • Audience Participation…Please! Update in Hospital Medicine Update in Hospital Medicine

  7. Syllabus/Bookkeeping • No conflicts of interest • Handouts available • ▪ Key slides • Final presentation via email: mhwa@medicine.ucsf.edu • Feedback also appreciated! Update in Hospital Medicine Update in Hospital Medicine

  8. Update in Hospital Medicine

  9. Case A 65 year-old man with a history of HTN and diabetes was admitted for CAP. On hospital day 5 he develops a fever, abdominal pain, and diarrhea. He appears ill and has a WBC of 22,000 and acute renal failure (Cre 2.2 mg/dL). A C diff test comes back positive. What is the optimal initial treatment? Update in Hospital Medicine Update in Hospital Medicine

  10. What is the optimal initial treatment? • Fidaxomicin PO • Vancomycin PO • Metronidazole PO • Vancomycin IV • Did someone order a stool transplant? Update in Hospital Medicine

  11. Management Clostridium difficile Question: What is the optimal management of Clostridium difficile infection? Design:Expert panel development of practice guideline; based on updated evidence ▪ SHEA: Society for Healthcare Epidemiology of America ▪ IDSA: Infectious Diseases Society of America Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431.

  12. Clostridium difficile • Origin? Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. Update in Hospital Medicine

  13. Of the people here at the conference, what percentage are colonized with C diff (assume none have been hospitalized recently)? • 90% • 50% • 10% • 2% • 0% • Geez, I can’t believe I just licked my fingers.

  14. Clostridium difficile • Origin • “it is on you, not in you” • Testing • “if the stool is not loose, the test is no use” • Severe C diff • WBC > 15,000 or • Acute renal failure (Cr 1.5x normal) Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. Update in Hospital Medicine

  15. Clostridium difficile • Origin • “it is on you, not in you” • Testing • “if the stool is not loose, the test is no use” • Severe C diff – WBC>15k or Cr > 1.5x • Treatment – Vanco for severe, metronidazole all others, 10-14 days Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. Update in Hospital Medicine

  16. Management Clostridium difficile Question: What is the optimal management of Clostridium difficileinfection? Design:Expert panel development of practice guideline; based on updated evidence Conclusion: Cdiff is spread by us; only send the test (once) on loose stool; Severe C diff (WBC, Cr) should be treated w/ Vancomycin; duration of tx 10-14 days Comment: Expert guideline, most evidence moderate to good; a common disease, follow the guidelines Wash your hands!!! Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431.

  17. What is the optimal initial treatment? • Fidaxomicin PO • Vancomycin PO • Metronidazole PO • Vancomycin IV • Did someone order a stool transplant? Update in Hospital Medicine

  18. Short Take: C diff & Antibiotic Exposure • In a retrospective cohort study including 10,154 hospitalizations there was a dose-dependent increase in the risk of C diff associated with: • Number of antibiotics • Cumulative antibiotic dose • Days of antibiotic exposure • Hospitalized patients who received 5 or more antibiotics were 10x more likely to develop C diff. Update in Hospital Medicine Update in Hospital Medicine Stevens V, et al. CID;2011;53:42.

  19. Case Continued The patient gets PO vancomycin and IVFs and remains on the floor. You wash your hands. Your resident is reviewing his medication list and notices that he is not on anything for “GI prophylaxis” (no PPI, H2 blocker, etc.). “Shouldn’t he be on some sort of GI prophylaxis?” Update in Hospital Medicine Update in Hospital Medicine

  20. What do you do for GI prophylaxis for this patient? Nothing Start a PPI Start an H2 blocker Tums. Tums. Tums. Tums. You’re staring at your Nexium pen, racking your brain, trying to remember what that rep told you at last night’s Purple PillTM dinner Update in Hospital Medicine Update in Hospital Medicine

  21. Acid-Suppression & Nosocomial GI Bleeding Question: For non-ICU inpatients, do PPIs or H2 blockers lower the incidence of nosocomial UGIB? Design: Observational cohort study; 79,287 adult inpatients; compared PPI or H2 blocker usage to no therapy. Update in Hospital Medicine Update in Hospital Medicine Herzig, SJ et al. Arch Int Med. 2011;171:991

  22. Results * With propensity scoring Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Herzig, SJ et al. Arch Int Med. 2011;171:991

  23. Results * With propensity scoring Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Herzig, SJ et al. Arch Int Med. 2011;171:991

  24. Results • Incidence of nosocomial UGIB: 0.29% • Incidence of clinically significant UGIB: 0.22% * With propensity scoring Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Herzig, SJ et al. Arch Int Med. 2011;171:991

  25. Results • Incidence of nosocomial UGIB: 0.29% • Incidence of clinically significant UGIB: 0.22% * With propensity scoring Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Herzig, SJ et al. Arch Int Med. 2011;171:991

  26. Acid-Suppressive & Nosocomial GI Bleeding Question: For non-ICU inpatients, do PPIs or H2 blockers lower the incidence of nosocomial GI bleeding? Design: Observational cohort study, 79,287 adult inpatients; compared PPI or H2 vs. nothing Conclusion: PPI or H2 blockers reduced bleeding. Incidence of nosocomial UGIB out of the ICU very low. Comments: Retrospective, administrative data Supports guidelines against routine usage of acid-suppressive medications outside the ICU. Update in Hospital Medicine Update in Hospital Medicine Herzig, SJ et al. Arch Int Med; 2011;171:991

  27. What do you do for GI prophylaxis for this patient? Nothing Start a PPI Start an H2 blocker Tums. Tums. Tums. Tums. You’re staring at your Nexium pen, racking your brain, trying to remember what that rep told you at last night’s Purple PillTM dinner Update in Hospital Medicine Update in Hospital Medicine

  28. Short Take: Proton Pump Inhibitors • In case-control studies, PPIs are associated with: • 2x increased risk of nosocomial C. diff infection • A 1.4x increased risk of C. diff recurrence after treatment • Increased incidence of both community (3x) and hospital-acquired pneumonia (1.3x) Arch Intern Med. 2010;170:747-748, 772-778, 784-790 Sarkar M. Ann Intern Med. 2008;149:391 Shoshana J, JAMA, 2009; 301:2120 Update in Hospital Medicine

  29. Case 1 Summary • Start • Considering that antibiotic exposure increases the risk for C diff. • Treating severe C diff (WBC > 15,000, Cr 1.5x baseline) with vancomycin. • Treating C diff for 10-14 days. • Washing your hands!!! • Stop • Sending C diff tests on non-diarrheal stool. • Prescribing “GI prophylaxis” for non-ICU patients. Update in Hospital Medicine

  30. Case Presentation A 60 year old man with severe necrotizing pancreatitis requires mechanical ventilation and pressors. On hospital day 3 you note a new infiltrate on CXR, fever, and increasing WBC. The ICU pharmacist says, “I think IDSA guidelines recommend linezolid over vancomycin for VAP.” You wonder, what is the optimal antibiotic regimen for this patient with suspected MRSA VAP? Update in Hospital Medicine Update in Hospital Medicine

  31. Vancomycin versus Linezolid, how would you respond? No change. Vancomycin is superior to linezolid. Maybe the pharmacist is right, I think there is evidence that linezolid is superior Doesn’t matter, they have similar efficacy I think it’s time for an ID consult Psssh…Vanco? Linezolid? It’s time to release the Tiger! (tigecycline) Update in Hospital Medicine Update in Hospital Medicine Walkey AJ, et al. Chest;2011;139:1148.

  32. Linezolid versus Glycopeptides for suspected MRSA Nosocomial PNA Question: In patients with suspected MRSA nosocomial pneumonia, is linezolid superior to vancomycin? Design: Meta-analysis of 8 RCTs of linezolid versus vancomycin Update in Hospital Medicine Update in Hospital Medicine Walkey AJ, et al. Chest;2011;139:1148.

  33. Results Update in Hospital Medicine Update in Hospital Medicine Walkey AJ, et al. Chest;2011;139:1148.

  34. Results Update in Hospital Medicine Update in Hospital Medicine Walkey AJ, et al. Chest;2011;139:1148.

  35. Results Update in Hospital Medicine Update in Hospital Medicine Walkey AJ, et al. Chest;2011;139:1148.

  36. Results Update in Hospital Medicine Update in Hospital Medicine Walkey AJ, et al. Chest;2011;139:1148.

  37. Linezolid versus Glycopeptides for suspected MRSA Nosocomial PNA Question: In patients with suspected MRSA nosocomial pneumonia, is linezolid superior to vancomycin? Design: Meta-analysis of 8 RCTs of linezolid versus vancomycin Conclusion: RCTs do not support superiority of linezolid over vancomycin Comments: Not powered to see difference in MRSA+ PNA. Don’t choose linezolid because of perceived superiority Update in Hospital Medicine Update in Hospital Medicine Walkey AJ, et al. Chest;2011;139:1148.

  38. Vancomycin versus Linezolid, how would you respond? No change. Vancomycin is superior to linezolid Maybe the pharmacist is right, I think there is evidence that linezolid is superior Doesn’t matter, they have similar efficacy I think it’s time for an ID consult Psssh…Vanco? Linezolid? It’s time to release the Tiger! (tigecycline) Update in Hospital Medicine Update in Hospital Medicine Walkey AJ, et al. Chest;2011;139:1148.

  39. Case Continued You start the patient on vancomycin and broad GNR coverage for VAP. Despite this, the patient does poorly. Respiratory cultures return as MRSA. Why isn’t the patient improving with a susceptible strain of MRSA? Should you change antibiotics? Update in Hospital Medicine

  40. Based on his vancomycin MIC and MRSA VAP you should: • Cont vanco, ensure trough is >15 • Change over to linezolid • Call your ID consultant to better understand the significance of this result • Treat with vancomycin and linezolid • Wait, didn’t you just tell me it didn’t make a difference? Make up your mind. Update in Hospital Medicine

  41. Vancomycin MIC in MRSA PNA Question: Do vancomycin MICs predict outcomes for MRSA PNA? Design:Observational cohort study, 158 pts, MRSA nosocomial PNA in ICU Looking at all cause mortality at 28 days Propensity scoring Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Harper SC, et al. CHEST. 2011;170:880.

  42. Results 32.3% of patients had died by day 28 Median and mean trough was 14 Patients were 3 times more likely to die with every 1mg/mL increase in Vancomycin MICs Most MRSA isolates had Vancomycin MICs of ≥1.5 mg/ml Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Harper SC, et al. CHEST. 2011;170:880.

  43. Vancomycin MIC in MRSA PNA Question: Do vancomycin MICs predict outcomes for MRSA PNA? Design: Observational cohort study, 158 pts, MRSA PNA in ICU Conclusion: Mortality increased with increasing vancomycin MICs, including those with MIC in “susceptible” range. Comment: Check those vanco MICs, consider alternatives if MIC between 1 and 2mg/mL, especially if patient not doing well Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Harper SC, et al. CHEST. 2011;170:880.

  44. Based on Vancomycin MICs of 2 in MRSA PNA you should: • Cont vanco, ensure trough is >15 • Change his antibiotics to linezolid • Consult ID to better understand the significance of this result • Treat with vancomycin and linezolid • Wait, didn’t you just tell me it didn’t make a difference? Make up your mind. Update in Hospital Medicine

  45. Case Continued While you are writing the order to switch to linezolid, the nurse points out his falling urine output, which is now 30cc/hr. You realize you can’t remember the last time you used the bathroom… and wonder who’s urine output is better, yours or your patients? Update in Hospital Medicine

  46. Short Take: UO in ICU providers Controlled trial comparing the urine output between residents and their patients during a month in the ICU. Doctors were found to be oliguric during 22% of their shifts and “in failure” in 1%. Doctors twice as likely than their patients to be oliguric (OR 1.99, CI 1.08 – 3.68) Thankfully, mortality among providers was low (0). Solomon, et al. BMJ;. 2010;341:6761 Update in Hospital Medicine Update in Hospital Medicine

  47. Case Continued While going to get a glass of water, you realize that you were planning on discharging that 65 year old woman admitted overnight for CAP. The radiology report on the CXR that showed infiltrate says, “consider interval follow up in 4-8 weeks.” You wonder, do I really need to get a follow-up chest xray? Update in Hospital Medicine

  48. Short Take: CXR after PNA Observational cohort following 3398 patients with confirmed CAP followed to determine incidence of and risk factors for new lung cancer. Tang, et al. Arch Int Med; 2011;171:1193. Update in Hospital Medicine Update in Hospital Medicine

  49. Short Take: CXR after PNA Risk factors for lung cancer included: Age >50 (aHR 19), male sex (aHR 1.8) and smoking history (aHR 1.7). Looking at pts >50 increases yield to 2.8%. Suggests incidence of diagnosing lung cancer after CAP is low and post-treatment CXR not needed in low-risk patients with resolving symptoms Tang, et al. Arch Int Med; 2011;171:1193. Update in Hospital Medicine Update in Hospital Medicine

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