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

Web ExclusivesJune 2021Annals for Hospitalists - June 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/AWHO202106150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesA Critical Look at Procalcitonin Testing in Pneumonia—Michael S. Pulia, MD, MS, and Peter K. Lindenauer, MD, MScIn this commentary, expert authors explain how they use procalcitonin testing in patients presenting with pneumonia.Highlights of Recent Articles From Annals of Internal MedicineAppropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of PhysiciansAnn Intern Med. 2021;174:822–827. Published 6 April 2021. doi:10.7326/M20-7355This narrative review examines the best practices for prescribing short-duration antibiotics for chronic obstructive pulmonary disease (COPD) exacerbations, community-acquired pneumonia (CAP), uncomplicated urinary tract infections, and cellulitis in adult patients. Although this article is not a formal systematic review, the authors considered the best available evidence in the literature, including published clinical guidelines, systematic reviews, and individual studies.Key points for hospitalists include:For COPD exacerbations with acute uncomplicated bronchitis and signs of bacterial infection (for example, purulent sputum with increased sputum volume and/or dyspnea), best practice is to limit antibiotic duration to 5 days.For CAP, best practice is to prescribe antibiotics for a minimum of 5 days. The course can be extended if a patient does not achieve clinical stability (defined as resolution of abnormal vital signs, ability to eat, and normal mentation).For uncomplicated cystitis in women, best practice is to prescribe a short course of antibiotics (for example, nitrofurantoin for 5 days, trimethoprim–sulfamethoxazole [TMP–SMZ] for 3 days, or fosfomycin as a single dose).For uncomplicated pyelonephritis in men and women, best practice is to prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP–SMZ (14 days) based on antibiotic susceptibility.For patients with nonpurulent cellulitis, without risk factors for methicillin-resistant Staphylococcus aureus infection, best practice is to prescribe a 5- to 6-day course of antibiotics active against streptococci, particularly for patients who are able to self-monitor and who have close follow-up with primary care.Development of Severe COVID-19 Adaptive Risk Predictor (SCARP), a Calculator to Predict Severe Disease or Death in Hospitalized Patients With COVID-19Ann Intern Med. 2021;174:777–785. Published 2 March 2021. doi:10.7326/M20-6754In this retrospective cohort study, investigators developed a tool to predict the probability of severe illness or death in adult patients hospitalized with symptomatic COVID-19. They applied a machine learning approach to data from a detailed registry of 3163 hospitalized patients with COVID-19 to develop the calculator. Respiratory parameters were the most important predictors, with the SpO2/FiO2 ratio being the most powerful. During the first week of hospitalization, the area under the receiver-operating characteristic curve for 1- and 7-day predictions of developing severe illness or death were 0.89 (95% CI, 0.88 to 0.90) and 0.83 (CI, 0.83 to 0.84), respectively.Key points for hospitalists include:The SCARP tool can predict the likelihood of severe disease or death for hospitalized patients with COVID-19 during the first 14 days of hospitalization and may help inform day-to-day provider–patient conversations about prognosis.The calculator is available online.One limitation of the study is that all of the data come from 5 hospitals in a single health system.A SARS-CoV-2 Cluster in an Acute Care HospitalAnn Intern Med. 2021;174:794–802. Published 9 February 2021. doi:10.7326/M20-7567This article describes an outbreak of COVID-19 occurring in a single U.S. hospital. The index case was a patient admitted with respiratory symptoms but with 2 negative nasopharyngeal polymerase chain reaction (PCR) tests for SARS-CoV-2 (obtained 12 hours apart). Respiratory isolation was discontinued for this patient who later tested positive for the virus on hospital day 11. Contact tracing and whole-genome sequencing discovered 14 patients and 38 employees who had been infected by the index case.Key points for hospitalists include:This case illustrates the low sensitivity of testing in the early stages of the disease and suggests that repeated testing over a greater period of time may be appropriate for some hospitalized patients.Thirteen percent of secondary infections were detected only on second or subsequent tests, illustrating that sequential testing is necessary to identify infected contacts who may initially have negative test results early after exposure.Several patients contracted the disease after sharing a room with an infected patient. Aerosol-generating procedures were not always present in these cases, raising the possibility that extended exposure in the room of an infected patient may lead to aerosol transmission, even if the beds are greater than 6 feet apart.Some employees contracted the virus despite the use of surgical masks and eye protection and in the absence of aerosol-generating procedures. Although this could be explained by self-contamination, it also raises the possibility that this degree of personal protective equipment may be insufficient for direct contact with highly contagious patients. Use of N95 or powered air-purifying respirators may be preferred in these situations.How Would You Manage This Patient With Nonvariceal Upper Gastrointestinal Bleeding? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAnn Intern Med. 2021;174:836-843. Published 8 June 2021. doi:10.7326/M21-1206This case-based article captures a Grand Rounds discussion in which 2 gastroenterologists provide answers to 3 controversial questions: 1. What are ideal blood transfusion goals for patients with nonvariceal upper gastrointestinal bleeding (UGIB)? 2. What is the optimal timing for endoscopy for patients with nonvariceal UGIB? 3. What is the recommended duration of postendoscopic proton-pump inhibitor (PPI) after bleeding peptic ulcer disease?Key points for hospitalists include:Transfusion threshold studies generally suggest that a restrictive transfusion threshold (for example, 7 to 8 g/dL) is noninferior or even superior to a liberal one (for example, 9 to 10 g/dL), but the discussants raise other considerations, such as the current rate of blood loss. One discussant suggests that because it is difficult to be certain about the current rate of bleeding, a more liberal transfusion strategy may provide a welcome margin of safety. The other aims to be more restrictive but is influenced by the patient's comorbidities and religious and personal beliefs.There are limited data to direct the timing of endoscopy. One randomized controlled trial showed no benefit to urgent endoscopy (<6 hours) compared with early endoscopy (6 to 24 hours). One discussant prefers earlier endoscopy, based partly on the notion that it may decrease length of stay and cost. The other is less convinced that earlier is better, noting that a period of resuscitation can stabilize the patient, and intravenous PPIs can decrease ulcer bleeding, facilitating the endoscopic procedure.Four to eight weeks of PPI therapy is curative for most ulcers with an identifiable and reversible cause if Helicobacter pylori is eradicated and nonsteroidal anti-inflammatory drugs are withdrawn. There is less evidence to guide the duration of PPI treatment of idiopathic bleeding ulcers. Use of PPIs should be extended in patients receiving aspirin or dual antiplatelet therapy.The Latest Highlights From Journal ClubHow does lung ultrasonography (LUS) compare with computed tomography (CT) in the diagnosis of COVID-19?In the ED, LUS and CT did not differ for sensitivity or specificity for diagnosing COVID-19 pneumoniaAnn Intern Med. 2021;174:JC57. doi:10.7326/ACPJ202105180-057In this prospective, observational study of 187 adult patients with COVID-19 symptoms, LUS (sensitivity 92% and specificity 71% vs. reverse transcriptase PCR [RT-PCR]) compared favorably with CT (sensitivity 88% and specificity 82% vs. RT-PCR) in diagnosing COVID-19.How do rapid antigen detection tests perform in the diagnosis of COVID-19?In suspected SARS-CoV-2, rapid antigen detection tests had 67% to 73% sensitivity and 98% to 100% specificityAnn Intern Med. 2021;174:JC56. doi:10.7326/ACPJ202105180-056Using RT-PCR as the diagnostic standard, this study of 5 different rapid antigen detection tests showed high specificity (98% to 100%) but poor sensitivity (67% to 83%), especially in patients with low viral loads.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 - A Critical Look at Procalcitonin Testing in Pneumonia Michael S. Pulia and Peter K. Lindenauer Metrics June 2021Volume 174, Issue 6Page: HO6 ePublished: 15 June 2021 Issue Published: June 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...