Annals for Hospitalists - 20 August 2019
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Web Exclusives20 August 2019Annals for Hospitalists - 20 August 2019FREEDavid H. Wesorick, MD* and Vineet Chopra, MD, MSc*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this author and Vineet Chopra, MD, MSc*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO201908200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesOptimal Treatment Duration for Patients Hospitalized With Pneumonia—The Benefits of Less—Scott A. Flanders, MDAre the antibiotics that you prescribe at hospital discharge helping your patients or harming them? In this commentary, an expert discusses the optimal antibiotic duration for patients with pneumonia, emphasizing the benefits of less.Highlights of Recent Articles from Annals of Internal MedicineExcess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort StudyAnn Intern Med. Published 9 July 2019. doi:10.7326/M18-3640This retrospective cohort study examined data from 6481 patients with community-acquired pneumonia (CAP) or health care–acquired pneumonia (HCAP), discharged from 43 Michigan hospitals between January 2017 and April 2018. The primary outcome was the rate of excess antibiotic treatment duration, calculated by subtracting the shortest effective duration (based on time to clinical stability, pathogen, and CAP vs. HCAP pneumonia classification) from the actual duration. Results showed that two thirds (67.8%) of patients received excess antibiotic therapy and that antibiotics prescribed at discharge accounted for 93.2% of this excess. Excess treatment was not associated with lower rates of death, readmission, or emergency department visits, nor was it associated with higher rates of provider-documented adverse effects (including Clostridium difficile infection). However, each excess day of antibiotics was associated with a 5% increase in the odds of patient-reported antibiotic-associated adverse events, including diarrhea, gastrointestinal distress, and mucosal candidiasis.Key points for hospitalists include:This study shows that most hospitalized, general care patients with CAP or HCAP received excess antibiotic treatment durations. Excess treatment was not associated with improved outcomes and was clearly associated with an increased rate of adverse events.Almost all of the excess antibiotic duration was attributed to antibiotics prescribed after hospital discharge.An accompanying editorial points out that the evidence for shorter antibiotic durations, for pneumonia and several other conditions, is now too strong to ignore and that clinicians, professional societies, regulatory agencies, and payers should all adopt the “shorter-is-better” mantra. Benefits and Harms of Oral Anticoagulant Therapy in Chronic Kidney Disease: A Systematic Review and Meta-analysisAnn Intern Med. Published 16 July 2019. doi:10.7326/M19-0087This large systematic review and meta-analysis (n = 34 082 in 45 randomized controlled trials [RCTs]) evaluated the benefits and harms of vitamin K antagonists (VKAs) and non–vitamin K oral anticoagulants (NOACs) in adults with stage 3 to 5 chronic kidney disease (CKD). Only 8 of the studies included patients receiving dialysis (and most of these trials were focused on use of warfarin to prevent thrombosis of dialysis access). Data synthesis reveals strong- or moderate-certainty evidence that NOACs are associated with lower rates of a composite of stroke or systemic embolism, as well as hemorrhagic stroke (but not nonhemorrhagic stroke), than VKAs in patients with atrial fibrillation (AF). In patients with venous thromboembolism (VTE), there was no difference between VKAs and NOACs with respect to several outcomes, including recurrent VTE or VTE-related death. Data in advanced CKD (requiring dialysis) were insufficient to establish benefits or harms for these agents.Key points for hospitalists include:In early stage CKD (creatinine clearance < 60 mL/min and > 20 mL/min), NOACs seem to have some advantages over VKAs for preventing hemorrhagic stroke and systemic embolism in patients with AF. However, no differences were observed between VKAs and NOACs used for the treatment of VTE.There are no studies of VKAs or DOACs in patients receiving dialysis who have VTE or AF (these patients have generally been excluded from these studies). Therefore, the efficacy and safety of these anticoagulants in such patients remains undefined.An editorial highlights the almost complete lack of evidence for the therapeutic use of anticoagulants in dialysis patients, despite their high incidence of AF and VTE, and points to 2 ongoing clinical trials that will provide much needed evidence in this area. Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysisAnn Intern Med. Published 6 August 2019. doi:10.7326/M19-1337This systematic review and meta-analysis evaluated 9 studies (n = 1189) comparing the diagnostic accuracy of standard clinical assessment versus clinical assessment with the addition of focused cardiac ultrasonography (FoCUS). The studies were all of a prospective cohort design, and almost all of them were at high or uncertain risk of bias. The analysis showed that the sensitivity for diagnosing left ventricular dysfunction, or mitral or aortic valve disease (as confirmed by formal echocardiography) was significantly greater with the addition of FoCUS, whereas specificity was not significantly improved.Key points for hospitalists include:This study adds to the growing body of literature demonstrating the benefits of enhancing the standard physical examination with focused use of ultrasonography.An editorial notes that, like many other studies of point-of-care ultrasonography, this study does not provide data on important clinical end points or the cost–benefit ratio of using the technology. The editorial also states that any added value of FoCUS depends on the skill and expertise of the user—especially awareness with regard to which questions FoCUS can definitively answer and which questions might require formal echocardiography. A Counterintuitive Tool for Connected CareAnn Intern Med. Published 16 July 2019. doi:10.7326/M19-0589In this Ideas and Opinions piece, the authors acknowledge the central role of computers in contemporary health care and the common perception that computers are pulling clinicians away from their patients. However, the authors suggest that the computer, rather than being a barrier between patients and providers, might actually be a useful tool for engagement and connection.Key points for hospitalists include:The authors recommend that providers engage patients by using the computer to show them radiographic images, trends in laboratory data, consultant recommendations, or other important information.Providers might also move from using the computer while away from the patient to directly collaborating with the patient while performing some computer tasks, such as medication reconciliation or writing orders. Engaging the patient in these activities creates transparency and encourages patients to ask questions and express preferences.Incorporating computers into patient encounters has the potential to allow clinicians to spend more time with their patients, while providing more effective care.The Latest Highlights From Journal ClubIn patients with atrial fibrillation and recent acute coronary syndrome or percutaneous coronary intervention, what is the safety and efficacy of vitamin K antagonists compared with apixaban, and what is the effect of adding aspirin?In AF with recent ACS or PCI, apixaban reduced bleeding vs. VKAs; aspirin increased bleeding vs placeboAnn Intern Med. 2019;171:JC7. doi:10.7326/ACPJ201907160-007This large (n = 4614) 2 x 2 factorial RCT compared VKAs with apixaban in combination with aspirin or placebo (in addition to a P2Y12) inhibitor, in patients with both atrial fibrillation and a recent acute coronary syndrome or percutaneous coronary intervention. The results showed that apixaban resulted in lower rates of bleeding, and a lower rate of a composite of death and hospitalization, but with a similar rate of a composite of death or thrombosis, compared with VKAs. The addition of aspirin resulted in higher rates of bleeding without a significant decrease in rates of hospitalization or death compared with placebo.How does point-of-care lung ultrasound compare with chest radiography for detecting pulmonary edema?Review: In acute dyspnea, lung US has higher sensitivity than chest X-ray for detecting cardiogenic pulmonary edemaAnn Intern Med. 2019; 171:JC11. doi: 10.7326/ACPJ201907160-011This systematic review and meta-analysis examined 6 studies (n = 1827) that compared the sensitivity and specificity of chest X-ray vs. lung ultrasound (LUS) for diagnosis of cardiogenic pulmonary edema in patients presenting with dyspnea. Pooled data demonstrate that LUS was more sensitive for pulmonary edema than chest X-ray (88% vs. 73%), with similar specificity.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Disclosures:Drs. Wesorick and Chopra have disclosed no conflicts of interest. The forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.* The authors are co-first authors and contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Optimal Treatment Duration for Patients Hospitalized With Pneumonia—The Benefits of Less Scott A. Flanders Metrics 20 August 2019Volume 171, Issue 4Page: HO4KeywordsAntibioticsComputersHemorrhageHemorrhagic strokeHospitalistsMedical dialysisPneumoniaSystematic reviewsThoraxUltrasound imaging ePublished: 20 August 2019 Issue Published: 20 August 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...