Newsflash: Hospital Medicine JOHN C. CHRISTENSEN, MD FACP AMERICAN COLLEGE OF PHYSICIANS, UTAH CHAPTER SCIENTIFIC MEETING FEBRUARY 10, 2017

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1 Newsflash: Hospital Medicine JOHN C. CHRISTENSEN, MD FACP AMERICAN COLLEGE OF PHYSICIANS, UTAH CHAPTER SCIENTIFIC MEETING FEBRUARY 10, 2017

2 Newsflash: Fluoroquinolones

3 Newsflash: Fluoroquinolones Don t use fluoroquinolones to treat the following: Acute bacterial sinusitis Acute bacterial exacerbations of chronic bronchitis Uncomplicated urinary tract infections

4 Newsflash: Fluoroquinolones Why not? Associated with disabling and potentially permanent: Tendonopathy (tendonitis & rupture) Arthralgias/myalgias Neuropathy/encephalopathy

5 Newsflash: Antibiotic Resistance

6 Newsflash: Antibiotic Resistance

7 Newsflash: Antibiotic Resistance The super bugs have arrived but what can I do about it? a) Nothing. It s inevitable. We re all going to die. b) We ll have new antibiotics soon that will take care of the problem. c) I m protected from all infectious agents by (insert your herbal remedy of choice here). d) Antibiotic stewardship.

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9 What is Antibiotic Stewardship The right: Drug Dose Route Duration Effect: Maximize clinical cure (or prevention of infection) and decrease risk of side effects.

10 What role do my specific antibiotic choices have? By choosing not to prescribe a Z-pack for your patient with a rhinovirus, you are decreasing antibiotic pressure on the local microbiome. In turn, this leaves all of us more likely to be able to use azithromycin in the future.

11 Benefits of Antimicrobial Stewardship? Improve infection cure rates Reduce C. difficile infection rates Improve patient safety Adverse drug events and toxicities, reduce SSIs Reduce antibiotic use 19.1% total use 26.6% restricted drugs Save money (approx. 33.9% of abx budget) Decrease LOS and resistance Public health imperative Gross R, et al. CID 2001; 33: White et al. CID 1997;25:230. Willemsen I et al. J Hosp Infect. 2007;67: Roberts GW et al. J Am Med Inform Assoc. 2010;17: Valiquette, et al. CID 2007;45:S112. Debast SB et al. Clin Microbiol Infect. 2009;15:427 Karanika S et al. Antimicrob. Agents Chemother. Online May 31

12 Newsflash: Clostridium difficile

13 Newsflash: Clostridium difficile Incidence of C.diff has doubled in the last decade C.diff now exceeds HIV in terms of mortality impact in last 20 years In developed countries, C.diff infection is the most common cause of infectious diarrhea in hospitalized patients National Hospital Discharge Statistics 2010 Bagdasarian et al. JAMA (4): 398 Hansen et al. JAMA Nov 22, (30):2149 Wilcox et al. NEJM Jan 26, 2017, 376(4):305

14 Newsflash: Clostridium difficile Spore forming gram positive anaerobic rod Toxin A Cytotoxin Toxin B Enterotoxin

15 Newsflash: Clostridium difficile Current treatment Metronidazole Vancomycin Fidaxomicin

16 Newsflash: Clostridium difficile Recurrence rates occur up to 35% following treatment for initial infection

17 Newsflash: Clostridium difficile Summarized two randomized, double blind, placebo controlled trials Actoxumab binds Toxin A Bezlotoxumab binds Toxin B

18 Newsflash: Clostridium difficile Participants had primary or recurrent C.diff infection and were receiving metronidazole, vancomycin, or fidaxomicin Randomized to: Single dose of actoxumab Single dose of bezlotoxumab Single doses of actoxumab and bezlotaxumab Placebo

19 Newsflash: Clostridium difficile Endpoint: Proportion of patients with recurrent C.diff infection at 12 weeks.

20 Kaplan Meier Plot of Time to Recurrent C. difficile Infection. Wilcox MH et al. N Engl J Med 2017;376:

21 Participants with Recurrent Clostridium difficile Infection during the 12-Week Follow-up Period. Wilcox MH et al. N Engl J Med 2017;376:

22 Newsflash: Clostridium difficile Issues: Cost We do not know which subgroups may benefit Age >65? Treatment with proton pump inhibitor? Severe C.diff? Renal failure? Ongoing need for antibiotics to treat another infection?

23 Newsflash: HCAP invalid? (HealthCare-Associated Pneumonia) 2005 ATS/IDSA released the criteria for HCAP to identify patients at risk for resistant organisms. If criteria was met, these patients were started on empiric vancomycin, anti-pseudomonal betalactam and a fluoroquinolone. Outcomes when using the HCAP treatment guidelines showed that patients did worse when compared to standard CAP treated patients. OR for mortality 2.18, 95% CI Jones BF. CID. 61: Attridge Eur Respir J 2011, 38:879

24 If not HCAP, then what?

25 DRIP Drug Resistance in Pneumonia Risk Factors Major Antibiotic use <60 days 2 Long-term care resident 2 Tube feeding 2 Prior drug-resistant pneumonia (1 year) Minor Hospitalization <60 day 1 Chronic pulmonary disease 1 Poor functional status 1 Gastric acid suppression 1 Wound care 1 MRSA colonization (1 year) 1 Points 2 DRIP score better identified patients at risk for infection with drug resistant pathogens. Patients with a score of 4 or greater, culture and empirically treat with: Vancomycin & Cefepime or Piperacillin-Tazo & Azithromycin Webb BJ, Antimicrob. Agents and Chemother. 2016; 60(5):

26 Newsflash: PE and Early Discharge

27 Newsflash: PE and Early Discharge 20. In patients with low-risk PE and whose home circumstances are adequate, we suggest treatment at home or early discharge over standard discharge (eg, after the first 5 days of treatment) (Grade 2B). Chest. 2016;149(2):

28 Newsflash: PE and Early Discharge What does this mean for outpatient providers? Need for prompt follow-up to ensure that the patient has filled their anticoagulants and is taking them. Monitor for side effects: dyspepsia (DOACs), injection site reactions (LMWHs), and bleeding. Ensure that the proper monitoring is in place (warfarin).

29 Newsflash: Pulmonary Embolism and Syncope October 20, 2016

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32 PE and Syncope Cross-sectional study Inclusion criteria >18 years old 1 st episode of syncope Hospitalized Exclusion criteria Prior syncope Anticoagulation Pregnancy

33 PE and Syncope Protocol History prodromal symptoms known cardiac dz recent bleeding volume depletion new medications VTE symptoms and risk factors (hx, surgery, immobilization, cancer) Physical Exam Vitals including orthostatics

34 PE and Syncope Testing CXR ECG ABG Routine blood work D-dimer

35 PE and Syncope Wells Score & D-dimer Negative D-dimer and Low Prob Wells Positive D-dimer or High Prob Wells PE ruled out Imaging PE ruled out PE

36 17.9% of the study participants were positive for PE

37 PE and Syncope Thrombotic burden CT pulmonary angiogram 41.7% main pulmonary artery 25% lobar artery 26.4% segmental artery 6.9% subsegmental artery V/Q scan 16.7% had a perfusion defect that was >50% of the area of both lungs. 33.3% had a perfusion defect that was 26-50% of both lungs. 50% had a perfusion defect that was 1-25% of both lungs.

38 PE and Syncope Syncope of unclear etiology 25.4% had PE Syncope with potential diagnosis other than PE 12.7% had PE Symptoms 24.7% had no signs, symptoms or history suggestive of VTE

39 Problems High prevalence of PE Not a treatment or outcome study Nevertheless the findings are significant enough that PE should be higher on the differential for syncope and it is worth taking the time to calculate a Wells Score and check a D-dimer.

40 Thank you