David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
In the study period from 2001 to 2012, the rate of CDI increased by 42.7%, but the rate of mrCDI increased by 188.8%. This finding suggests that the incidence of mrCDI is increasing at a disproportionate rate compared with CDI, in general.
Patients who have mrCDI were more likely to be older; to be female; or to have used antibiotics, proton-pump inhibitors, or corticosteroids in the previous 90 days. They also were more likely to have chronic kidney disease or to be a nursing home resident at the time of diagnosis (odds ratios for all <2).
An accompanying editorial describes this study as an important first step in understanding the epidemiology of mrCDI because it will allow targeted application of new and costly treatments (e.g., bezlotoxumab, fecal microbiota transplant) for patients at the highest risk for mrCDI.
A subgroup of the studies at lower risk of bias in this review suggests that dose reduction or discontinuation of long-term opioid therapy may result in improvements in pain severity, function, and quality of life.
Heterogeneity of interventions in this review precludes identification of an optimal approach for achieving dose reduction or discontinuation of long-term opioid use. However, multidisciplinary care and close follow-up are common themes to most successful interventions.
An accompanying editorial states that while additional, higher quality studies are needed, the existing data suggest that patients really do benefit from efforts to reduce the dose of long-term opioid therapy.
Clinicians should have a low threshold for screening patients for HIV infection. Furthermore, the Centers for Disease Control and Prevention recommends that persons between the ages of 13 and 64 years should be tested for HIV at least once as part of routine health care. Indications for screening hospitalized patients may include high-risk behaviors or risk factors, patient requests for testing, clinical suspicion of acute or chronic HIV infection, or clinical suspicion of an opportunistic infection.
Acute HIV infection should be considered when patients present with fever, fatigue, myalgia/arthralgia, lymphadenopathy, pharyngitis, rash, neurologic syndromes (e.g., meningitis, encephalitis, radiculopathy), hepatitis, or gastrointestinal symptoms.
Screening for HIV should employ the fourth-generation HIV-1/2 antigen/antibody combination test, with positive results followed by an HIV-1/2 differentiation test. If acute HIV infection is suspected and the antigen/antibody test result is negative or indeterminate, then an HIV quantitative RNA polymerase chain reaction assay should be performed.
Testing for HIV should also be considered when evaluating possible opportunistic infections, the most common being Pneumocystis pneumonia, esophageal candidiasis, cryptococcal meningitis, and toxoplasma encephalitis. Testing is also appropriate in patients presenting with lymphadenopathy or lymphoma, and in patients with signs or symptoms that might be consistent with chronic HIV or AIDS (e.g., thrombocytopenia, low lymphocyte fraction, recurrent vaginal candidiasis, oral thrush, unexplained weight loss, fever, or night sweats).
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Wesorick DH, Chopra V. Annals for Hospitalists - 15 August 2017. Ann Intern Med. ;167:HO1. doi: 10.7326/AFHO201708150
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Published: Ann Intern Med. 2017;167(4):HO1.
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