American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News

for the Week of 1-12-11



Highlights

New guidelines set out MRSA treatments

The Infectious Diseases Society of America released its first set of guidelines on the treatment of methicillin-resistant Staphylococcus aureus last week. More...

Guidelines revised to cover new pulmonary fungal infections

New guidance on the treatment of fungal infections in pulmonary and critical care patients was released by the American Thoracic Society on Jan. 1. More...


Venous thromboembolism

Score quantifies risk factors at admission for in-hospital bleeding

Researchers have developed a new score to identify at admission those acutely ill patients at high risk of in-hospital bleeding, which may assist physicians in using venous thromboembolism prophylaxis. More...


Sepsis

Initially inappropriate antibiotic therapy lengthens sepsis patients' stay by two days

Nearly one-third of patients with severe sepsis and septic shock attributable to Gram-negative organisms receive inappropriate antibiotic therapy at first, which prolongs their hospital stay by two days on average, a study found. More...


Influenza

CDC issues guidance on rapid influenza tests

Rapid influenza tests can be useful in diagnosis and treatment, but they often yield false-negative results, the CDC recently cautioned. More...


From ACP Internist

The January issue is online

The next issue of ACP Internist is online. Included in this issue are stories on treating chronic sinusitis, and talking to patients about cancer risk. More...


Cartoon Caption Contest

Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner. More...


Physician editor: A. Scott Keller, FACP




Highlights


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New guidelines set out MRSA treatments

The Infectious Diseases Society of America released its first set of guidelines on the treatment of methicillin-resistant Staphylococcus aureus (MRSA) last week.

The guidelines were developed by an expert panel of infectious disease specialists and cover MRSA infections associated with health care facilities (HA-MRSA) as well as those acquired in the community (CA-MRSA). The guidelines note that the "so-called CA-MRSA isolates" are genetically distinct from HA-MRSA and susceptible to many non-ß-lactam antibiotics. Recommendations are provided on the appropriate treatment—both antibiotic and non-drug—of skin and soft-tissue infections, from simple abscesses seen in the outpatient setting to complicated infections in hospitalized patients.

The guidelines also discuss management of recurrent MRSA skin and soft-tissue infections, recommending education on personal hygiene for all patients, with decolonization and oral therapy reserved for patients in whom other measures are unsuccessful. Appropriate antibiotic and other therapy for MRSA bacteremia and infective endocarditis, MRSA pneumonia, and MRSA infections in bones, joints and the central nervous system are also covered in the guidelines, which will appear in the Feb. 1 Clinical Infectious Diseases. Local variations in epidemiology should be considered by physicians implementing the guidelines, the authors noted.

The guidelines provide advice on vancomycin therapy, including the limitations of vancomycin susceptibility testing. If testing indicates a vancomycin minimum inhibitory concentration (MIC) of ≤2 µg/mL, the patient's clinical response should determine the continued use of vancomycin independent of the MIC. If the MIC is greater than 2 µg/mL (i.e., VISA or VRSA), an alternative drug should be used. The guidelines recommend dosing and monitoring vancomycin according to a previous consensus statement from the IDSA and other groups. The new guidelines have been endorsed by the Pediatric Infectious Diseases Society, the American College of Emergency Physicians and the American Academy of Pediatrics.

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Guidelines revised to cover new pulmonary fungal infections

New guidance on the treatment of fungal infections in pulmonary and critical care patients was released by the American Thoracic Society (ATS) on Jan. 1.

The clinical policy statement replaces ATS guidelines published in 1988, which primarily covered only fungal infections in patients with HIV. Since then, the incidence, diagnosis and clinical severity of pulmonary fungal infections have increased dramatically, according to the statement. The increase is attributable to growing numbers of patients with immune compromise due to malignancy or hematologic disease as well as HIV, in addition to the population of patients taking immunosuppressive drugs. New technologies have also made definitive diagnosis easier, the statement noted.

The statement offers advice on treatment of endemic mycoses, including histoplasmosis, sporotrichosis, blastomycosis and coccidioidomycosis. It also covers the fungal infections that are most common among immune-compromised and critically ill patients, such as cryptococcosis, aspergillosis, candidiasis and Pneumocystis pneumonia. Finally, recommendations are offered on the treatment of rare and emerging fungi: zygomycosis, hyalohyphomycosis, phaeohyphomycosis and infections related to Trichosporon.

The guidelines cover traditional antifungal agents, including amphotericin, itraconazole and fluconazole, but recommendations are also provided on the use of newer pharmacologic options, such as novel lipid forms of amphotericin B and the echinocandins, a new class of antifungal agents that inhibit the formation of the cell walls of fungi. The statement was published in the Jan. 1 American Journal of Respiratory and Critical Care Medicine.

The new advice should guide physicians in treatment of fungal infections now, and may also be useful in responses to other fungal infections that emerge, said the chair of the ATS working group that developed the statement. The working group is also considering writing a separate statement focused entirely on the diagnosis of fungal infections, which would assess both old and new diagnostic tools.

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Venous thromboembolism


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Score quantifies risk factors at admission for in-hospital bleeding

Researchers have developed a new score to identify at admission those acutely ill patients at high risk of in-hospital bleeding, which may assist physicians in using venous thromboembolism (VTE) prophylaxis.

The researchers used data from 15,156 medical patients from the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) trial, a multinational, observational study that examined VTE prophylaxis patterns and clinical outcomes in hospitalized patients with acute illness. They estimated in-hospital bleeding incidence by Kaplan-Meier analysis, and used a multiple regression model analysis to identify risk factors at admission associated with bleeding. Results were published in the January Chest.

The cumulative bleeding incidence 14 days after admission was 3.2% (1.2% major bleeding and 2.1% nonmajor but clinically relevant bleeding). The most common sites of major bleeding were gastrointestinal, large hematoma and intracranial; gastrointestinal bleeding was also the most common site of nonmajor but clinically relevant bleeding. The strongest independent risk factors at admission for bleeding were active gastroduodenal ulcer (odds ratio [OR], 4.15; 95% CI, 2.21 to 7.77; P<0.001), bleeding in the three months prior to admission (OR, 3.64; 95% CI, 2.21 to 5.99; P<0.001) and platelet count of less than 50 × 109 cells/L (OR, 3.37; 95% CI 1.84 to 6.18; P<0.001). Other significant risk factors were age ≥85 years vs. <40 years, hepatic failure (international normalized ratio >1.5), renal failure, ICU stay, central venous catheter use, rheumatic disease, cancer and male sex. Researchers developed a bleeding risk score based on these factors, for which the highest possible number of points is 33. They found that bleeding risk began to increase exponentially in patients with a risk score of ≥7.0 points (about 10% of patients in the study).

The bleeding risk score, which can be determined via a calculator online, could be useful when making decisions about the type of VTE prophylaxis to use (mechanical or pharmaceutical) in acutely ill patients, the authors said. Physicians should use caution when prescribing anticoagulant prophylaxis to patients with a risk score ≥7.0, and determine management on a case-by-case basis, they added. Most patients will score below 7.0, however, and "our data indicate that physicians can be reassured that the bleeding risk in these patients is not significantly elevated by in-hospital provision of anticoagulant prophylaxis," they wrote. A study strength is that the IMPROVE registry offers "real-world" data on a representative population of acutely ill patients with risk factors for both VTE and bleeding, they noted. A weakness is that the risk score wasn't validated in an external population, "an essential next step" before the model can be recommended, the authors said.

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Sepsis


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Initially inappropriate antibiotic therapy lengthens sepsis patients' stay by two days

Nearly one-third of patients with severe sepsis and septic shock attributable to Gram-negative organisms receive inappropriate antibiotic therapy at first, which prolongs their hospital stay by two days on average, a study found.

Researchers retrospectively reviewed patients with Gram-negative bacteremia and severe sepsis or septic shock at an urban academic hospital over a six-year period. The final cohort included 760 patients, 55% of whom had nosocomial infections. Escherichia coli was the most common pathogen (29.6% of patients); Pseudomonas species were isolated in 17.4% of patients. Most patients were treated in the ICU (78.9%); urine was the most common site of primary infection (51%), followed by the lung (38.8%). Researchers defined initially inappropriate antibiotic therapy as occurring when a patient either was not given an antibiotic within 24 hours of sepsis onset, or was treated with an antibiotic to which the pathogen was resistant. Results were published in the January Critical Care Medicine.

Thirty-one percent of patients received initially inappropriate antibiotic therapy. Those who did were more likely to have a nosocomial infection (69.3% vs. 48.7%; P=0.001); require chronic hemodialysis (14.7% vs. 7.1%; P=0.001); undergo mechanical ventilation (62.6% vs. 51.5%; P=0.005); or have diabetes (27.5% vs. 20.1%; P=0.034). These patients also had an unadjusted mean length of stay (after sepsis onset) of 11 days, compared to nine days in those treated appropriately (P=0.028 by log-rank test). They also had a greater hospital mortality (51.7% vs. 36.4%; P=0.001). Initially inappropriate therapy independently correlated with continued hospitalization in a Cox model that controlled for multiple cofounders like comorbid diseases and illness severity (adjusted hazard ratio, 1.19; 95% CI, 1.01 to 1.40; P=0.044).

Other studies have noted that initially inappropriate antibiotic treatment increases mortality for sepsis patients; this study adds to the analysis by focusing on a different end point—length of stay, the authors noted. By noting the economic costs of a longer length of stay, "physicians can make a strong case to hospital administrators and national policymakers" about the value of addressing initially inappropriate antibiotic therapy, and of treating patients aggressively, they wrote. Ways to minimize inappropriate therapy include creating antibiotic prescribing protocols, routinely discussing antibiotic management strategies in multidisciplinary meetings, and consulting earlier with infectious disease specialists, the authors wrote.

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Influenza


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CDC issues guidance on rapid influenza tests

Rapid influenza tests can be useful in diagnosis and treatment, but they often yield false-negative results, the CDC recently cautioned.

In a guidance statement released in December, the CDC outlined the appropriate use of rapid influenza tests for the 2010-2011 influenza season. The tests are easy to use and yield results in 15 minutes or less, making them helpful for confirmation of outbreaks, especially in institutional settings. However, they have limited sensitivity and predictive value, the agency said. Because of the high risk for false-negative results, a patient who tests negative but has signs and symptoms of flu should not be excluded from antiviral treatment. Testing is not always necessary in all patients, especially in a community known to already be affected by influenza. The CDC listed the following factors as potential influences on rapid-test accuracy:

  • clinical signs and symptoms of influenza,
  • prevalence of influenza in the population tested,
  • time from illness onset to collection of respiratory specimens for testing,
  • type of respiratory specimen tested, and
  • accuracy of the test compared to a reference test, such as reverse transcriptase polymerase chain reaction or viral culture.

To minimize false results, the CDC recommends that clinicians collect specimens as early as possible after illness onset (ideally within four days), follow manufacturer's instructions on acceptable specimens and appropriate handling, and confirm negative results with a reference test if a laboratory-confirmed diagnosis is needed.

The full guidance statement, which includes additional information on test interpretation and clinical algorithms to assist in decision making, is available online.

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From ACP Internist


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The January issue is online

The next issue of ACP Internist is online. Included in this issue are:

Miserable symptoms mark chronic sinusitis. Distinctive clues can lead internists to deliver the right treatment for chronic sinusitis, an illness that can feel as symptomatically miserable as congestive heart failure or rheumatoid arthritis.

Speaking of cancer: Tips on how to convey risk to patients. How physicians express cancer risks to patients determines how they might use that knowledge to make decisions about genetics, family history and potential future screens and tests.

Practice achieves NCQA's highest recognition without an EMR. An internal medicine practice followed evidence-based diabetes care guidelines and achieved honors from the National Committee on Quality Assurance, despite not yet having an electronic medical record.

Also, don't miss the latest Test Yourself with the MKSAP Quiz.

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Cartoon Caption Contest


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Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner.

acph-20110112-cartoon.jpg

"This is not quite what I meant by androgen blockade."

"Given how you feel, Erik, maybe watchful waiting is a better way to go."

"I'll be gentler than the TSA agent."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Jan. 24, with the winner announced in the Jan. 26 issue.

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