Annals for Hospitalists - May 2021
Authors: David H. Wesorick, Jawad Al-Khafaji, Matthew Luzum
Journal: Annals of Internal Medicine (2021)

Web ExclusivesMay 2021Annals for Hospitalists - May 2021FREEDavid H. Wesorick, MD*, Jawad Al-Khafaji, MD, MSHA*, Matthew Luzum, MD*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, J.A., M.L.)Search for more papers by this author, Jawad Al-Khafaji, MD, MSHA*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, J.A., M.L.)Search for more papers by this author, Matthew Luzum, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, J.A., M.L.)Search for more papers by this authorAuthor, Article and Disclosure Informationhttps://doi.org/10.7326/AWHO202105180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Clinical Pearls—Methicillin-Resistant Staphylococcus aureus Bacteremia—Steven Y. C. Tong, MBBS, PhDIn this commentary, an expert author highlights key principles for managing patients with S aureus bacteremia.Highlights of Recent Articles From Annals of Internal MedicineThrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19Ann Intern Med. 2021;174:622–632. Published 26 January 2021. doi:10.7326/M20-6739This multicenter, retrospective cohort study evaluated the incidence of venous thromboembolism (VTE) and major bleeding in 3239 critically ill adults with COVID-19 from 67 U.S. hospitals within 14 days after intensive care unit (ICU) admission. During that time frame, 204 patients (6.3%) developed VTE (associated with 38.2% mortality at 28 days), and 90 patients (2.8%) developed a major bleeding event (associated with 62.2% mortality). A target trial emulation including 2809 patients (in whom VTE had not been diagnosed or suspected) compared those who were empirically treated with therapeutic anticoagulation within the first 2 days of ICU admission (n = 384) with those receiving only standard prophylactic anticoagulation (n = 2425). Of those receiving early therapeutic anticoagulation, 179 (46.6%) died during a median follow-up of 27 days, compared with 887 (36.6%) deaths among those not treated with early therapeutic anticoagulation.Key points for hospitalists include:The 2 independent predictors of VTE in critically ill patients with COVID-19 were male sex and higher D-dimer level on ICU day 1.Although major bleeding incidence was only about half of the VTE incidence, the 28-day mortality was much higher in patients with major bleeding.There was no benefit of early therapeutic anticoagulation overall or in any subgroup (including those with male sex and elevated D-dimer level) compared with prophylactic anticoagulation.Study limitations include the observational study design, the possible underestimation of VTE and major bleeding events given the limited 14-day study period, and underestimation of VTE incidence related to the logistic challenges of imaging in critically ill patients with COVID-19.Major Update: Remdesivir for Adults With COVID-19: A Living Systematic Review and Meta-analysis for the American College of Physician Practice PointsAnn Intern Med. 2021;174:663–672. Published 9 February 2021. doi:10.7326/M20-8148Should Remdesivir Be Used for the Treatment of Patients With COVID-19? Rapid, Living Practice Points From the American College of Physicians (Version 2)Ann Intern Med. 2021;174:673–679. Published 9 February 2021. doi:10.7326/M20-8101These articles represent an update to a previously published systematic review and accompanying clinical guideline. The updated review now includes the results of ACTT-1 (Adaptive COVID-19 Treatment Trial) (previously included as a preliminary report) and data from a new randomized controlled trial (RCT) (World Health Organization Solidarity trial). The updated analysis concludes that a 10-day course of remdesivir probably results in little to no difference in mortality compared with the control group overall. However, post hoc subgroup analysis suggests that the effect on mortality depends on severity of illness at the time of remdesivir initiation—there is little to no effect on mortality in patients with no oxygen requirement, a small reduction in mortality in patients requiring oxygen support without ventilation, and a moderate increase in mortality in patients requiring mechanical ventilation (MV) or extracorporeal membrane oxygenation (ECMO). Notably, remdesivir results in a moderate increase in the proportion of patients who recover or improve and a large reduction in the time to clinical recovery. The updated clinical practice points are summarized below.Key points for hospitalists include:The guideline suggests that remdesivir be considered for 5 days to treat hospitalized patients with COVID-19 who do not require MV or ECMO. Given low certainty of evidence, this recommendation was changed from “use remdesivir” to “consider remdesivir.”The guideline suggests that clinicians consider extending the course of remdesivir to 10 days in hospitalized patients with COVID-19 who are started on remdesivir treatment before needing MV or ECMO but then go on to require MV or ECMO within a 5-day course of treatment. (Evidence was believed to be insufficient to recommend extension to 10 days in patients who are requiring noninvasive ventilation or oxygen therapy after 5 days of treatment.)The guideline suggests that clinicians avoid initiating remdesivir in patients with COVID-19 who are already receiving MV or ECMO.Characteristics, Outcomes, and Trends of Patients With COVID-19–Related Critical Illness at a Learning Health System in the United StatesAnn Intern Med. 2021;174:613–621. Published 19 January 2021. doi:10.7326/M20-5327This multihospital, retrospective cohort study describes the epidemiology of COVID-19–related critical illness. Among 468 patients admitted to an ICU between 1 March and 11 May 2020, a total of 319 (68.2%) received MV, and 121 (25.9%) received vasopressors. The all-cause, in-hospital, 28-day mortality rate was 29.9%; median ICU stay was 8 days; and median hospital stay was 13 days. The all-cause, 30-day readmission rate was 10.8%. Mortality decreased over time by about half (from 43.5% to 19.2%).Key points for hospitalists include:This study provides informative data about the disease course of critically ill patients with COVID-19.The authors suggest that the observed decrease in mortality over time may be related to increasing adherence to emerging best practices in COVID-19 care.The generalizability of these results is limited by the fact that these data come from 5 hospitals within a single hospital system.The Latest Highlights From Journal ClubHow does rivaroxaban compare with warfarin for patients with atrial fibrillation (AF) and a bioprosthetic mitral valve?In patients with AF and a bioprosthetic mitral valve, rivaroxaban was noninferior to warfarin for time to clinical eventsAnn Intern Med. 2021;174:JC43. doi:10.7326/ACPJ202104200-043This RCT compared rivaroxaban with warfarin in 1005 patients with AF and a bioprosthetic mitral valve. Rivaroxaban was noninferior to warfarin for time to the composite outcome of death, major cardiovascular events, or major bleeding at 12 months.In patients with iron deficiency who are hospitalized with acute heart failure (HF), does intravenous (IV) iron treatment improve outcomes?In acute HF and iron deficiency, IV ferric carboxymaltose reduced HF hospitalizations, but not CV death, at 1 yearAnn Intern Med. 2021;174:JC45. doi:10.7326/ACPJ202104200-045This RCT compared IV ferric carboxymaltose versus placebo (administered at the time of discharge and again at 6 weeks, and then at weeks 12 and 24 if deficiency persisted) in 1132 patients with iron deficiency who were admitted with HF. Patients in the IV iron group had significantly fewer HF readmissions, but not lower mortality, at 1 year.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, J.A., M.L.)Disclosures:Drs. Wesorick, Al-Khafaji, and Luzum have disclosed no conflicts of interest. The forms can be viewed at http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-1311.* The authors contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Clinical Pearls—Methicillin-Resistant Staphylococcus aureus Bacteremia Steven Y.C. Tong Metrics May 2021Volume 174, Issue 5Page: HO5 ePublished: 18 May 2021 Issue Published: May 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...