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Update in Hospital Medicine

Alpesh N. Amin, MD, MBA; and Michael J. Pistoria, DO*
[+] Article and Author Information

From University of California, Irvine, Orange, California, and Lehigh Valley Hospital, Allentown, Pennsylvania.


*Adapted for publication in Annals of Internal Medicine by Jennifer Fisher Wilson and Michael Berkwits, MD, MSCE.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Alpesh N. Amin, MD, MBA, Department of Medicine, University of California, Irvine, 101 The City Drive South, Building 58, Room 110, ZC-4076H, Orange, CA 92868; e-mail, anamin@uci.edu.

Current Author Addresses: Dr. Amin: Department of Medicine, University of California, Irvine, 101 The City Drive South, Building 58, Room 110, ZC-4076H, Orange, CA 92868.

Dr. Pistoria: Department of Medicine, Lehigh Valley Hospital, 1240 South Cedar Crest Boulevard, Suite 410, Allentown, PA 18103.


Ann Intern Med. 2007;147(9):628-632. doi:10.7326/0003-4819-147-9-200711060-00007
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This update reviews the past year's most important articles relevant to hospital medicine.

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Missing the point?
Posted on November 2, 2007
Christopher M. Hughes
St. Clair Memorial Hospital
Conflict of Interest: None Declared
Thanks to Drs. Amin and Pistoria for their Update in Hospital Medicine. I found something quite interesting in their "clinical bottom line" findings, particularly reagarding care for Acute Coronary Syndromes, switching to oral antibiotics, reducing central line infections, medication reconciliation, diagnosis of DVT and PE and pay for performance. The common thread here is that we cannot practice medicine in an error free way on our own any longer, if ever we could. The days of remembering that "[f]or patients with non"“ST-segment elevation ACS, prescribe aspirin, a ß-blocker, heparin, and intravenous glycoprotein IIb/IIIa inhibitors at presentation and aspirin, a ß-blocker, clopidogrel, an angiotensin-converting enzyme inhibitor, and lipid-lowering medication at discharge unless contraindicated," and "[i]n inpatients with severe pneumonia, consider switching from intravenous to oral antibiotics after 3 days," are gone. Medical systems and patient care are so complex that, yes, we should remember to do those things, but I don't want to count on my physician simply remembering to do all the right things all the time. These studies, and the hundreds like them, are calling on us to participate in quality improvement projects within our institutions. Whining about "cook book" medicine is no longer acceptable. Mindless variation and idiosyncratic practice are no longer acceptable. We need to actively participate in improving care for our profession and for our patients. If our best physicians are not shaping our guidelines and standardized order sets, then who is? Often it is a single physician (or two) at a committee meeting trying to fashion policy and procedure in a virtual clinical vacuum because others are too busy to participate. The central theme, as I see it, is that we need to step up to the plate and turn the research into clinical practice in our individual practices and institutions. If we cannot afford to give up the time, then perhaps we should force the issue and demand compensation for our time and effort from hospitals, health plans and others. Or perhaps we should insist on clinical/administrative teams whose job it is to assist us in this process so that when we spend our time, it is supported wisely and vigorously. Sincerely,

Conflict of Interest:

None declared

Be careful what you wish for
Posted on November 3, 2007
Lynn Bentson
Firstcare Physicians
Conflict of Interest: None Declared

We are admonished, cajoled and financially rewarded when we adhere to guidelines. Some of them are based on controlled trials, some on expert opinion and most of them on both. One set which is being enforced via core measures is antibiotic choices in pneumonia. I might remind our readers that we are currently mandated to use classes of antibiotics in pneumonia that have strong associations with C difficile. Is there a hospital in this country that isn't awash in patients who are on contact precautions for C diff ? We are now supposed to give antibiotics for pneumonia earlier . I am sure I am the only one in this nation who has an older person with a poor quality chest X-ray and altered level of consciousness admitted from a busy ER with the diagnosis of pneumonia who has no fever, no leukocytosis, no cough, no hypoxemia, but who does have new atrial fibrillation or cholecystitis or a fracture. The antibiotics don't help much and they do contribute to our spectacular rates of MRSA as well. Well, the contact precautions will be in place for C Diff anyway, right?

The discharge guidelines give us the frail elder being sent home on Sunday after being admitted for pneumonia . This patient has a new insulin regime, which is needed to control sugars having been on steroids at the GOLD criteria dosing guidelines but they are having the steroids , and we hope the insulin, tapered. They also have new warfarin, along with aspirin , with their antibiotics because they had a troponin of 0.4 while they were in atrial fibrillation with their pneumonia .Their PCP, should they be lucky enough to have one, is already double booked in 3 spots for Monday before the office even opens. If everything goes perfectly this person may get to voicemail by 2 pm. Discharge guidelines also give us the patient who can't get SNF placement because they have CHF and COPD with or without osteoporosis and the mandated treatments for both give them more than seven meds , and an accepting facility gets dinged for polypharmacy.

Treating patients with the best available regimes and making sure that at 2 o'clock in the morning the drugs are there, the reminders are there and the nurses can read the orders is terrific. Having a rudimentary understanding of outpatient medicine is even better. Using our training to develop a differential diagnosis and understanding that treatments can sometimes harm our patients is the best of all .

Conflict of Interest:

None declared

Response to the Update in Hospital Medicine
Posted on November 7, 2007
Eric M Mortensen
South Texas Veterans Health Care System
Conflict of Interest: None Declared

To the editor: We read with great interest the recent Update in Hospital Medicine (1). This summary, which discussed the article by Oosterheert et al. (2) "Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial", overplayed the strength of this article and we disagree strongly with the summary's recommendations. The primary article was an outstanding randomized controlled trial (2) that examined two strategies of conversion of intravenous to oral antimicrobial therapy in patients hospitalized with community- acquired pneumonia. Unfortunately, this article had several limitations including not having a true cohort of subjects with severe pneumonia, as the overall 28-day mortality was 5% versus the generally accepted 20-30% (3), and they excluded subjects who required intubation or intensive care unit admission. In addition, this study utilized antibiotics regimes, which at least in the United States would be considered inappropriate (4), and have been associated with increased mortality as compared to other antimicrobial regimes concordant with the American Thoracic Society/Infectious Diseases Society of America clinical practice guidelines (4, 5). Therefore the Updates' recommendation, based on a single article with major limitations, to switch patients hospitalized with pneumonia from intravenous to oral antibiotics at 3 days is inappropriate. We agree with the authors that there is a need to switch patients from intravenous to oral therapy as soon as possible, but we recommend the use of the well-validated criteria that already exist (4). Furthermore, it is important to recognize that there are many factors that must be taken into consideration including the patient's condition, bacterial resistance and the antibiotic pharmacokinetics (4). Additional research and validation is needed prior to recommending an aggressive management strategy for severe pneumonia, which has 30-day mortality rates approaching 30%.

References

1. Amin AN, Pistoria MJ. Update in Hospital Medicine. Annals of Internal Medicine. 2007;147:628-632.

2. Oosterheert JJ, Bonten MJ, Schneider MM, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial. BMJ. 2006.

3. Angus DC, Marrie TJ, Obrosky DS, et al. Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria. Am J Respir Crit Care Med. 2002;166(5):717-23.

4. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious diseases society of america/american thoracic society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72.

5. Mortensen EM, Restrepo M, Anzueto A, Pugh J. Effects of guideline- concordant antimicrobial therapy on mortality among patients with community-acquired pneumonia. Am J Med. 2004;117(10):726-31.

Conflict of Interest:

None declared

Switch Therapy in Severe CAP Patients
Posted on February 7, 2008
Alpesh N. Amin
University of California, Irvine
Conflict of Interest: None Declared

TO THE EDITOR: We thank the author(s) for their recent letter to the editor in regards to Amin and Pistoria's "Update in Hospital Medicine" (1), in reference to the article by Oosterheert et al. entitled "Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomized trial" (2). We acknowledge that the original article by Oosterheert has potential limitations (some of which were listed in the letter to editor), but the concept of intravenous to oral switch therapy has been documented in the literature as a strategy for care in Community Acquired Pneumonia (CAP). The 2007 combined IDSA/ATS guidelines (3) for CAP gives a strong recommendation with level II evidence, stating patients should be switched from intravenous to oral therapy when they are hemodynamically stable, improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. The concept of early switch to oral antibiotics in CAP patients has been shown to allow for early discharge and reduce drug and treatment costs. Studies in the past have only evaluated mild to moderate disease, while Oosterheert's study is the first to look at the potential role for early switch therapy in severe CAP patients. Such studies are needed to determine if early switch strategy works in sicker patients.

We appreciate that the antibiotic regimen is different from the US, but this Netherlands study based its antibiotics choice on local Dutch guidelines. We recommend that a similar study be repeated in the US for severe CAP patients using local US guidelines. Having said that, the 2007 IDSA/ATS recommends that one does not switch antibiotics but continues with the regimen started and shown to be effective in the hospital or at least stay with the same class of antibiotics. So the concept of switch therapy may be more important to maintain the same class of antibiotics and the question of which antibiotic to start with should be based on the local guidelines.

One should not read more into the Oosterheert's study than what it is. It is a good randomized control trial that is the first to suggest that early transition to oral antibiotics may be safely implemented in severe CAP patients who do not need treatment in the ICU utilizing local published guidelines for antibiotic choice. This strategy may reduce intravenous treatment and hospital length of stay. Further studies are recommended.

Alpesh N. Amin, MD, MBA University of California, Irvine

Michael J. Pistoria, DO Lehigh Valley Hospital

References

1. Amin AN, Pistoria MJ. Update in Hospital Medicine. Annals of Internal Medicine. 2007;147:628-632.

2. Oosterheert JJ, Bonten MJ, Schneider MM, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial. BMJ. 2006.

3. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious diseases society of america/american thoracic society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72.

Conflict of Interest:

None declared

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