The Hospitalist

MADRID – Seven days of antibiotic therapy was just as effective as 14 days for patients with Gram-negative bacteremias.

The shorter course was associated with similar cure rates and a faster return to normal activities, Dafna Yahav, MD, said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Michele G. Sullivan/MDedge News

“In patients hospitalized with Gram-negative bacteremia and sepsis, a course of 7 antibiotic days was not inferior to 14 days, and resulted in a more rapid return to baseline activity, “ said Dr. Yahav of the Rabin Medical Center, Petah Tikva, Israel. “This could lead to a change in accepted management algorithms and shortened antibiotic therapy. Potentially, though we did not show this in our trial, it may lead to reduced cost, reduced development of resistance, and fewer adverse events.”

During the past few years, a new dogma has emerged in antibiotic treatment paradigms, she said: Shorter is better. Brad Spellberg, MD, described this concept in his 2016 editorial in JAMA Internal Medicine, “The new antibiotic mantra” (Sep 1;176[9]:1254-5).

In it, Dr. Spellberg, of the University of Southern California, Los Angeles, addressed the long-held view that a full 10- or 14-day course of antibiotics was necessary to decrease the risk of creating a resistant strain, even if clinical symptoms were long resolved.

However, he noted, there is little evidence supporting the idea that longer courses suppress the rise of resistance – and, in fact, some data support the opposite.

“To the contrary, specifically for pneumonia, studies have shown that longer courses of therapy result in more emergence of antibiotic resistance, which is consistent with everything we know about natural selection, the driver of antibiotic resistance,” he noted. “In only a few types of infections does resistance emerge at the site of infection; rather, resistance typically emerges off target, among colonizing flora away from the site of infection. Thus, all that is achieved by treating an infection with antibiotics for longer than the patient has symptoms is increased selective pressure driving antibiotic resistance among our colonizing microbial flora.”

The primary outcome was a composite 90-day endpoint of all-cause mortality, clinical failure (relapse, new local complications, or distant complications), and readmission or hospital stay longer than 14 days. There were a number of secondary outcomes, including new infection, emergence of antibiotic resistance, total hospital and total antibiotic days, time to return to baseline activity, and adverse events.

The cohort was a mean of 71 years old. About 60% were functionally independent, and the mean Charlson comorbidity score was 2. Most of the infections (90%) were nosocomial. The urinary tract was the largest source of infection (69%). Other sources were abdominal, respiratory, central venous catheter, and skin or soft tissue.

Escherichia coli was the most common infective organism (62%), followed by Klebsiella species and Enterobacteriaceae. A small number of patients had Acinetobacter and Pseudomonas infections.

In the intent-to-treat analysis, the primary composite outcome of all-cause mortality or extended hospital stay occurred in 46% of the 7-day group and 50% of the 14-day group – not significantly different. The results were nearly identical in the per-protocol analysis (46% vs. 49.6%).

[email protected]

SOURCE: Yahav D et al. ECCMID 2018. Oral abstract O1120.

MADRID – Seven days of antibiotic therapy was just as effective as 14 days for patients with Gram-negative bacteremias.

The shorter course was associated with similar cure rates and a faster return to normal activities, Dafna Yahav, MD, said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Michele G. Sullivan/MDedge News

“In patients hospitalized with Gram-negative bacteremia and sepsis, a course of 7 antibiotic days was not inferior to 14 days, and resulted in a more rapid return to baseline activity, “ said Dr. Yahav of the Rabin Medical Center, Petah Tikva, Israel. “This could lead to a change in accepted management algorithms and shortened antibiotic therapy. Potentially, though we did not show this in our trial, it may lead to reduced cost, reduced development of resistance, and fewer adverse events.”

During the past few years, a new dogma has emerged in antibiotic treatment paradigms, she said: Shorter is better. Brad Spellberg, MD, described this concept in his 2016 editorial in JAMA Internal Medicine, “The new antibiotic mantra” (Sep 1;176[9]:1254-5).

In it, Dr. Spellberg, of the University of Southern California, Los Angeles, addressed the long-held view that a full 10- or 14-day course of antibiotics was necessary to decrease the risk of creating a resistant strain, even if clinical symptoms were long resolved.

However, he noted, there is little evidence supporting the idea that longer courses suppress the rise of resistance – and, in fact, some data support the opposite.

“To the contrary, specifically for pneumonia, studies have shown that longer courses of therapy result in more emergence of antibiotic resistance, which is consistent with everything we know about natural selection, the driver of antibiotic resistance,” he noted. “In only a few types of infections does resistance emerge at the site of infection; rather, resistance typically emerges off target, among colonizing flora away from the site of infection. Thus, all that is achieved by treating an infection with antibiotics for longer than the patient has symptoms is increased selective pressure driving antibiotic resistance among our colonizing microbial flora.”

The primary outcome was a composite 90-day endpoint of all-cause mortality, clinical failure (relapse, new local complications, or distant complications), and readmission or hospital stay longer than 14 days. There were a number of secondary outcomes, including new infection, emergence of antibiotic resistance, total hospital and total antibiotic days, time to return to baseline activity, and adverse events.

The cohort was a mean of 71 years old. About 60% were functionally independent, and the mean Charlson comorbidity score was 2. Most of the infections (90%) were nosocomial. The urinary tract was the largest source of infection (69%). Other sources were abdominal, respiratory, central venous catheter, and skin or soft tissue.

Escherichia coli was the most common infective organism (62%), followed by Klebsiella species and Enterobacteriaceae. A small number of patients had Acinetobacter and Pseudomonas infections.

In the intent-to-treat analysis, the primary composite outcome of all-cause mortality or extended hospital stay occurred in 46% of the 7-day group and 50% of the 14-day group – not significantly different. The results were nearly identical in the per-protocol analysis (46% vs. 49.6%).

[email protected]

SOURCE: Yahav D et al. ECCMID 2018. Oral abstract O1120.

MADRID – Seven days of antibiotic therapy was just as effective as 14 days for patients with Gram-negative bacteremias.

The shorter course was associated with similar cure rates and a faster return to normal activities, Dafna Yahav, MD, said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Michele G. Sullivan/MDedge News

“In patients hospitalized with Gram-negative bacteremia and sepsis, a course of 7 antibiotic days was not inferior to 14 days, and resulted in a more rapid return to baseline activity, “ said Dr. Yahav of the Rabin Medical Center, Petah Tikva, Israel. “This could lead to a change in accepted management algorithms and shortened antibiotic therapy. Potentially, though we did not show this in our trial, it may lead to reduced cost, reduced development of resistance, and fewer adverse events.”

During the past few years, a new dogma has emerged in antibiotic treatment paradigms, she said: Shorter is better. Brad Spellberg, MD, described this concept in his 2016 editorial in JAMA Internal Medicine, “The new antibiotic mantra” (Sep 1;176[9]:1254-5).

In it, Dr. Spellberg, of the University of Southern California, Los Angeles, addressed the long-held view that a full 10- or 14-day course of antibiotics was necessary to decrease the risk of creating a resistant strain, even if clinical symptoms were long resolved.

However, he noted, there is little evidence supporting the idea that longer courses suppress the rise of resistance – and, in fact, some data support the opposite.

“To the contrary, specifically for pneumonia, studies have shown that longer courses of therapy result in more emergence of antibiotic resistance, which is consistent with everything we know about natural selection, the driver of antibiotic resistance,” he noted. “In only a few types of infections does resistance emerge at the site of infection; rather, resistance typically emerges off target, among colonizing flora away from the site of infection. Thus, all that is achieved by treating an infection with antibiotics for longer than the patient has symptoms is increased selective pressure driving antibiotic resistance among our colonizing microbial flora.”

The primary outcome was a composite 90-day endpoint of all-cause mortality, clinical failure (relapse, new local complications, or distant complications), and readmission or hospital stay longer than 14 days. There were a number of secondary outcomes, including new infection, emergence of antibiotic resistance, total hospital and total antibiotic days, time to return to baseline activity, and adverse events.

The cohort was a mean of 71 years old. About 60% were functionally independent, and the mean Charlson comorbidity score was 2. Most of the infections (90%) were nosocomial. The urinary tract was the largest source of infection (69%). Other sources were abdominal, respiratory, central venous catheter, and skin or soft tissue.

Escherichia coli was the most common infective organism (62%), followed by Klebsiella species and Enterobacteriaceae. A small number of patients had Acinetobacter and Pseudomonas infections.

In the intent-to-treat analysis, the primary composite outcome of all-cause mortality or extended hospital stay occurred in 46% of the 7-day group and 50% of the 14-day group – not significantly different. The results were nearly identical in the per-protocol analysis (46% vs. 49.6%).

[email protected]

SOURCE: Yahav D et al. ECCMID 2018. Oral abstract O1120.

MADRID – Three days of beta-lactam therapy was just as effective as 8 days for clinically stable patients presenting with community-acquired pneumonia.

In a randomized, placebo-controlled trial, 15-day cure rates were 69.9% in patients who took 3 days of antibiotics and 61.2% in those who took 8 days – a nonsignificant difference, Aurélien Dinh, MD, said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Michele G Sullivan/MDedge News

[email protected]

SOURCE: Dinh et al. ECCMID 2018, Oral Abstract O1126.

MADRID – Three days of beta-lactam therapy was just as effective as 8 days for clinically stable patients presenting with community-acquired pneumonia.

In a randomized, placebo-controlled trial, 15-day cure rates were 69.9% in patients who took 3 days of antibiotics and 61.2% in those who took 8 days – a nonsignificant difference, Aurélien Dinh, MD, said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Michele G Sullivan/MDedge News

[email protected]

SOURCE: Dinh et al. ECCMID 2018, Oral Abstract O1126.

MADRID – Three days of beta-lactam therapy was just as effective as 8 days for clinically stable patients presenting with community-acquired pneumonia.

In a randomized, placebo-controlled trial, 15-day cure rates were 69.9% in patients who took 3 days of antibiotics and 61.2% in those who took 8 days – a nonsignificant difference, Aurélien Dinh, MD, said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Michele G Sullivan/MDedge News

[email protected]

SOURCE: Dinh et al. ECCMID 2018, Oral Abstract O1126.

SANDESTIN, FLA. – More than ever, clinicians need to rely on a multimodal approach to pain management, Katherine Galluzzi, DO, said at the annual Congress of Clinical Rheumatology.

In the era of opioid addiction – in which she said physicians have sometimes been unfairly vilified – pharmaceutical options are limited not only by the threat of abuse but also by governmental regulation, explained Dr. Galluzzi, chair of geriatrics at the Philadelphia College of Osteopathic Medicine.

The underpinning of pain management in the future will need to be cognitive-behavioral therapy, such as changing behavior and meditation; physical approaches, such as exercise and acupuncture; and interventional treatments, such as nerve blocks and trigger-point injections. Pharmacotherapy can’t do it all, nor should it, she said.

“This is what we have, this is what we need to do,” Dr. Galluzzi said. “This impacts the quality of life, and patients need to begin providing self-care. It’s not going to come in the form of a pill. It has to be a commitment between the patient and the physician.”

The Centers for Medicare & Medicaid Services are proposing a new limit on opioid prescriptions for Medicare recipients – a maximum of 90 morphine mg equivalents per day for no more than 7 days. That will affect older people, who are most likely to be in need of pain management, she said. Those on hospice care and experiencing certain cancer pain will be exempt, she noted in an interview.

Concerns about addiction to drugs such as gabapentin and benzodiazepines might make these therapies less of an option in coming years, Dr. Galluzzi added.

Risk evaluation and mitigation strategy training is an important tool for helping physicians weigh the benefits and the risks of opioid prescriptions. Dr. Galluzzi particularly suggests enrolling in a 3-4 hour, in-person program, saying that it’s well worth the time.

“If you haven’t done a risk assessment and mitigation strategies course and you’re an opioid prescriber,” she said, “I highly recommend that you do that.”

SANDESTIN, FLA. – More than ever, clinicians need to rely on a multimodal approach to pain management, Katherine Galluzzi, DO, said at the annual Congress of Clinical Rheumatology.

In the era of opioid addiction – in which she said physicians have sometimes been unfairly vilified – pharmaceutical options are limited not only by the threat of abuse but also by governmental regulation, explained Dr. Galluzzi, chair of geriatrics at the Philadelphia College of Osteopathic Medicine.

The underpinning of pain management in the future will need to be cognitive-behavioral therapy, such as changing behavior and meditation; physical approaches, such as exercise and acupuncture; and interventional treatments, such as nerve blocks and trigger-point injections. Pharmacotherapy can’t do it all, nor should it, she said.

“This is what we have, this is what we need to do,” Dr. Galluzzi said. “This impacts the quality of life, and patients need to begin providing self-care. It’s not going to come in the form of a pill. It has to be a commitment between the patient and the physician.”

The Centers for Medicare & Medicaid Services are proposing a new limit on opioid prescriptions for Medicare recipients – a maximum of 90 morphine mg equivalents per day for no more than 7 days. That will affect older people, who are most likely to be in need of pain management, she said. Those on hospice care and experiencing certain cancer pain will be exempt, she noted in an interview.

Concerns about addiction to drugs such as gabapentin and benzodiazepines might make these therapies less of an option in coming years, Dr. Galluzzi added.

Risk evaluation and mitigation strategy training is an important tool for helping physicians weigh the benefits and the risks of opioid prescriptions. Dr. Galluzzi particularly suggests enrolling in a 3-4 hour, in-person program, saying that it’s well worth the time.

“If you haven’t done a risk assessment and mitigation strategies course and you’re an opioid prescriber,” she said, “I highly recommend that you do that.”

SANDESTIN, FLA. – More than ever, clinicians need to rely on a multimodal approach to pain management, Katherine Galluzzi, DO, said at the annual Congress of Clinical Rheumatology.

In the era of opioid addiction – in which she said physicians have sometimes been unfairly vilified – pharmaceutical options are limited not only by the threat of abuse but also by governmental regulation, explained Dr. Galluzzi, chair of geriatrics at the Philadelphia College of Osteopathic Medicine.

The underpinning of pain management in the future will need to be cognitive-behavioral therapy, such as changing behavior and meditation; physical approaches, such as exercise and acupuncture; and interventional treatments, such as nerve blocks and trigger-point injections. Pharmacotherapy can’t do it all, nor should it, she said.

“This is what we have, this is what we need to do,” Dr. Galluzzi said. “This impacts the quality of life, and patients need to begin providing self-care. It’s not going to come in the form of a pill. It has to be a commitment between the patient and the physician.”

The Centers for Medicare & Medicaid Services are proposing a new limit on opioid prescriptions for Medicare recipients – a maximum of 90 morphine mg equivalents per day for no more than 7 days. That will affect older people, who are most likely to be in need of pain management, she said. Those on hospice care and experiencing certain cancer pain will be exempt, she noted in an interview.

Concerns about addiction to drugs such as gabapentin and benzodiazepines might make these therapies less of an option in coming years, Dr. Galluzzi added.

Risk evaluation and mitigation strategy training is an important tool for helping physicians weigh the benefits and the risks of opioid prescriptions. Dr. Galluzzi particularly suggests enrolling in a 3-4 hour, in-person program, saying that it’s well worth the time.

“If you haven’t done a risk assessment and mitigation strategies course and you’re an opioid prescriber,” she said, “I highly recommend that you do that.”

Approximately one in four specialty medical practices employs nurse practitioners or physician assistants, based on data from a review of approximately 90% of physician practices in the United States.

The employment of advanced practice clinicians in primary care continues to grow, but their presence in specialty practices has not been well studied, wrote Grant R. Martsolf, PhD, of the University of Pittsburgh, and his colleagues. In a study published in JAMA Internal Medicine, the researchers used the proprietary SK&A data set to examine employment in specialty practices between 2008 and 2016.

Overall, 28% of all specialty practices employed advanced practice clinicians in 2016 – a 22% increase from 2008. Nearly half of multispecialty practices (49%) employed advanced practice clinicians, as did at least 25% of dermatology, cardiology, obstetrics-gynecology, orthopedic surgery, and gastroenterology practices.

Plastic surgery and ophthalmology practices were the least likely to employ advanced practice clinicians. Surgical practices were more likely to employ physician assistants than nurse practitioners, but the other specialty practices were more likely to employ NPs than PAs.

The growth in employment of advanced practice clinicians may be driven by factors such as economics and the expanding roles for advanced practice clinicians in specialty practice, the researchers said.

The findings were limited by the inclusion of outpatient providers only, and by the lack of information about the exact duties of advanced practice clinicians in each practice, the researchers noted. However, the results suggest that advanced practice clinicians will become even more prevalent in specialty care, and “future research will need to understand their contributions to access, quality, and value,” they wrote.

The researchers had no financial conflicts to disclose.

SOURCE: Martsolf GR et al. JAMA Intern Med. 2018 Apr 30. doi: 10.1001/jamainternmed.2018.1515 .

Approximately one in four specialty medical practices employs nurse practitioners or physician assistants, based on data from a review of approximately 90% of physician practices in the United States.

The employment of advanced practice clinicians in primary care continues to grow, but their presence in specialty practices has not been well studied, wrote Grant R. Martsolf, PhD, of the University of Pittsburgh, and his colleagues. In a study published in JAMA Internal Medicine, the researchers used the proprietary SK&A data set to examine employment in specialty practices between 2008 and 2016.

Overall, 28% of all specialty practices employed advanced practice clinicians in 2016 – a 22% increase from 2008. Nearly half of multispecialty practices (49%) employed advanced practice clinicians, as did at least 25% of dermatology, cardiology, obstetrics-gynecology, orthopedic surgery, and gastroenterology practices.

Plastic surgery and ophthalmology practices were the least likely to employ advanced practice clinicians. Surgical practices were more likely to employ physician assistants than nurse practitioners, but the other specialty practices were more likely to employ NPs than PAs.

The growth in employment of advanced practice clinicians may be driven by factors such as economics and the expanding roles for advanced practice clinicians in specialty practice, the researchers said.

The findings were limited by the inclusion of outpatient providers only, and by the lack of information about the exact duties of advanced practice clinicians in each practice, the researchers noted. However, the results suggest that advanced practice clinicians will become even more prevalent in specialty care, and “future research will need to understand their contributions to access, quality, and value,” they wrote.

The researchers had no financial conflicts to disclose.

SOURCE: Martsolf GR et al. JAMA Intern Med. 2018 Apr 30. doi: 10.1001/jamainternmed.2018.1515 .

Approximately one in four specialty medical practices employs nurse practitioners or physician assistants, based on data from a review of approximately 90% of physician practices in the United States.

The employment of advanced practice clinicians in primary care continues to grow, but their presence in specialty practices has not been well studied, wrote Grant R. Martsolf, PhD, of the University of Pittsburgh, and his colleagues. In a study published in JAMA Internal Medicine, the researchers used the proprietary SK&A data set to examine employment in specialty practices between 2008 and 2016.

Overall, 28% of all specialty practices employed advanced practice clinicians in 2016 – a 22% increase from 2008. Nearly half of multispecialty practices (49%) employed advanced practice clinicians, as did at least 25% of dermatology, cardiology, obstetrics-gynecology, orthopedic surgery, and gastroenterology practices.

Plastic surgery and ophthalmology practices were the least likely to employ advanced practice clinicians. Surgical practices were more likely to employ physician assistants than nurse practitioners, but the other specialty practices were more likely to employ NPs than PAs.

The growth in employment of advanced practice clinicians may be driven by factors such as economics and the expanding roles for advanced practice clinicians in specialty practice, the researchers said.

The findings were limited by the inclusion of outpatient providers only, and by the lack of information about the exact duties of advanced practice clinicians in each practice, the researchers noted. However, the results suggest that advanced practice clinicians will become even more prevalent in specialty care, and “future research will need to understand their contributions to access, quality, and value,” they wrote.

The researchers had no financial conflicts to disclose.

SOURCE: Martsolf GR et al. JAMA Intern Med. 2018 Apr 30. doi: 10.1001/jamainternmed.2018.1515 .

Clinical question: What guidance is there for clinical care of complex heart failure patients?

Background: The prevalence of heart failure (HF)is escalating and consumes significant health care resources, inflicts significant morbidity and mortality, and greatly affects quality of life. There is a plethora of research, multiple medical therapies, devices, and care strategies that have been shown to improve outcomes in heart failure patients. Previous publications have reviewed evidence-based literature but left a gap in knowledge for those more-complex areas or lacked practical clinical guidance. This policy document was created to guide physicians in informed decision making in a directed decision pathway form.

Study design: Expert consensus guidelines.

Setting: American College of Cardiology Task Force on Expert Consensus Decision Pathways.

Synopsis: A multidisciplinary group of specialties including physicians, nurses, pharmacists, epidemiologists, and patient advocacy groups addressed 10 pivotal issues in heart failure through literature review, expert consensus, and round table discussion.

Ten principles were identified and addressed:

• Initiating, adding, or switching to new evidenced-based guideline-directed therapy.
• Achieving optimal therapy using multiple HF drugs and therapies.
• Knowing when to refer a patient to an HF specialist.
• Addressing the challenges of care coordination for team-based HF treatment.
• Improving patient adherence.
• Managing specific patient cohorts, such as African Americans, older adults, and the frail.
• Managing your patients’ cost of care for HF.
• Reducing costs and managing the increased complexity of HF.
• Managing the most common cardiac and noncardiac comorbidities.
• Integrating palliative care and transitioning patients to hospice care

Bottom line: Structured guidelines to provide practical and actionable recommendations to improve heart failure outcomes, integrate evidence-based medicine when available, and utilize expert conscious when evidence-based medicine is not available.

Citation: Yancy CW et al. 2017 ACC expert consensus on decision pathway for optimizing of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol. 2018 Jan 16;71(2):201-30.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What guidance is there for clinical care of complex heart failure patients?

Background: The prevalence of heart failure (HF)is escalating and consumes significant health care resources, inflicts significant morbidity and mortality, and greatly affects quality of life. There is a plethora of research, multiple medical therapies, devices, and care strategies that have been shown to improve outcomes in heart failure patients. Previous publications have reviewed evidence-based literature but left a gap in knowledge for those more-complex areas or lacked practical clinical guidance. This policy document was created to guide physicians in informed decision making in a directed decision pathway form.

Study design: Expert consensus guidelines.

Setting: American College of Cardiology Task Force on Expert Consensus Decision Pathways.

Synopsis: A multidisciplinary group of specialties including physicians, nurses, pharmacists, epidemiologists, and patient advocacy groups addressed 10 pivotal issues in heart failure through literature review, expert consensus, and round table discussion.

Ten principles were identified and addressed:

• Initiating, adding, or switching to new evidenced-based guideline-directed therapy.
• Achieving optimal therapy using multiple HF drugs and therapies.
• Knowing when to refer a patient to an HF specialist.
• Addressing the challenges of care coordination for team-based HF treatment.
• Improving patient adherence.
• Managing specific patient cohorts, such as African Americans, older adults, and the frail.
• Managing your patients’ cost of care for HF.
• Reducing costs and managing the increased complexity of HF.
• Managing the most common cardiac and noncardiac comorbidities.
• Integrating palliative care and transitioning patients to hospice care

Bottom line: Structured guidelines to provide practical and actionable recommendations to improve heart failure outcomes, integrate evidence-based medicine when available, and utilize expert conscious when evidence-based medicine is not available.

Citation: Yancy CW et al. 2017 ACC expert consensus on decision pathway for optimizing of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol. 2018 Jan 16;71(2):201-30.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What guidance is there for clinical care of complex heart failure patients?

Background: The prevalence of heart failure (HF)is escalating and consumes significant health care resources, inflicts significant morbidity and mortality, and greatly affects quality of life. There is a plethora of research, multiple medical therapies, devices, and care strategies that have been shown to improve outcomes in heart failure patients. Previous publications have reviewed evidence-based literature but left a gap in knowledge for those more-complex areas or lacked practical clinical guidance. This policy document was created to guide physicians in informed decision making in a directed decision pathway form.

Study design: Expert consensus guidelines.

Setting: American College of Cardiology Task Force on Expert Consensus Decision Pathways.

Synopsis: A multidisciplinary group of specialties including physicians, nurses, pharmacists, epidemiologists, and patient advocacy groups addressed 10 pivotal issues in heart failure through literature review, expert consensus, and round table discussion.

Ten principles were identified and addressed:

• Initiating, adding, or switching to new evidenced-based guideline-directed therapy.
• Achieving optimal therapy using multiple HF drugs and therapies.
• Knowing when to refer a patient to an HF specialist.
• Addressing the challenges of care coordination for team-based HF treatment.
• Improving patient adherence.
• Managing specific patient cohorts, such as African Americans, older adults, and the frail.
• Managing your patients’ cost of care for HF.
• Reducing costs and managing the increased complexity of HF.
• Managing the most common cardiac and noncardiac comorbidities.
• Integrating palliative care and transitioning patients to hospice care

Bottom line: Structured guidelines to provide practical and actionable recommendations to improve heart failure outcomes, integrate evidence-based medicine when available, and utilize expert conscious when evidence-based medicine is not available.

Citation: Yancy CW et al. 2017 ACC expert consensus on decision pathway for optimizing of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol. 2018 Jan 16;71(2):201-30.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Long-acting inhaled bronchodilator use (LABA or LAMA) in patients with COPD is the mainstay of treatment. Prior studies have reported a possible interaction between LABA or LAMA use and increased rates of cardiovascular events; however, the results have been variable. The findings have been confounded by incomplete medical records, exclusion of patients with CVD in bronchodilator trials, and high patient drop out rates. This study aims to assess the association between LABA or LAMA use in patients with COPD and the risk of CVD.

Study design: Nested case control study.

Setting: Taiwanese national database.

Synopsis: This study included 284,200 LABA and LAMA naive patients who were aged 40 years or older and had COPD (mean age, 71.4 years); it retrieved health care claims data from 2007 through 2011 for these patients from the Taiwan National Health Insurance Research Database. During a mean follow-up of 2.0 years, 37,719 patients experienced a cardiovascular event, and 146,139 matched controls were identified. LABA or LAMA use was measured in the year preceding the cardiovascular event and stratified by duration since initiation of LABA or LAMA treatment. Logistical regression was performed to estimate the odds ratios of CVD from LABA and LAMA treatment. New LABA use was associated with a 1.50-fold (95% confidence interval, 1.35-1.67; P less than .001) increased cardiovascular risk within 30 days of initiation, and new LAMA use was associated with a 1.52 fold (95% CI, 1.28-1.80; P less than .001) increased risk. In patients with prevalent LABA or LAMA use, the risk of CVD was absent or reduced.

Key limitations included the omission of contributors to cardiovascular disease, including smoking status and alcohol consumption, in the final analysis. Also, the contribution of worsening COPD to cardiovascular events was not accounted for.

Bottom line: Initiation of inhaled LABAs or LAMAs in patients with COPD is associated with a 1.5-fold increased risk of cardiovascular disease – including emergency or inpatient care for coronary artery disease, heart failure, ischemic stroke, or arrhythmia – in the first 30 days.

Citation: Wang MT et al. Association of cardiovascular risk with inhaled long-acting bronchodilators in patients with chronic obstructive pulmonary disease. JAMA Intern Med. 2018; 178(2):229-38.

Dr. Skinner is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Long-acting inhaled bronchodilator use (LABA or LAMA) in patients with COPD is the mainstay of treatment. Prior studies have reported a possible interaction between LABA or LAMA use and increased rates of cardiovascular events; however, the results have been variable. The findings have been confounded by incomplete medical records, exclusion of patients with CVD in bronchodilator trials, and high patient drop out rates. This study aims to assess the association between LABA or LAMA use in patients with COPD and the risk of CVD.

Study design: Nested case control study.

Setting: Taiwanese national database.

Synopsis: This study included 284,200 LABA and LAMA naive patients who were aged 40 years or older and had COPD (mean age, 71.4 years); it retrieved health care claims data from 2007 through 2011 for these patients from the Taiwan National Health Insurance Research Database. During a mean follow-up of 2.0 years, 37,719 patients experienced a cardiovascular event, and 146,139 matched controls were identified. LABA or LAMA use was measured in the year preceding the cardiovascular event and stratified by duration since initiation of LABA or LAMA treatment. Logistical regression was performed to estimate the odds ratios of CVD from LABA and LAMA treatment. New LABA use was associated with a 1.50-fold (95% confidence interval, 1.35-1.67; P less than .001) increased cardiovascular risk within 30 days of initiation, and new LAMA use was associated with a 1.52 fold (95% CI, 1.28-1.80; P less than .001) increased risk. In patients with prevalent LABA or LAMA use, the risk of CVD was absent or reduced.

Key limitations included the omission of contributors to cardiovascular disease, including smoking status and alcohol consumption, in the final analysis. Also, the contribution of worsening COPD to cardiovascular events was not accounted for.

Bottom line: Initiation of inhaled LABAs or LAMAs in patients with COPD is associated with a 1.5-fold increased risk of cardiovascular disease – including emergency or inpatient care for coronary artery disease, heart failure, ischemic stroke, or arrhythmia – in the first 30 days.

Citation: Wang MT et al. Association of cardiovascular risk with inhaled long-acting bronchodilators in patients with chronic obstructive pulmonary disease. JAMA Intern Med. 2018; 178(2):229-38.

Dr. Skinner is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Long-acting inhaled bronchodilator use (LABA or LAMA) in patients with COPD is the mainstay of treatment. Prior studies have reported a possible interaction between LABA or LAMA use and increased rates of cardiovascular events; however, the results have been variable. The findings have been confounded by incomplete medical records, exclusion of patients with CVD in bronchodilator trials, and high patient drop out rates. This study aims to assess the association between LABA or LAMA use in patients with COPD and the risk of CVD.

Study design: Nested case control study.

Setting: Taiwanese national database.

Synopsis: This study included 284,200 LABA and LAMA naive patients who were aged 40 years or older and had COPD (mean age, 71.4 years); it retrieved health care claims data from 2007 through 2011 for these patients from the Taiwan National Health Insurance Research Database. During a mean follow-up of 2.0 years, 37,719 patients experienced a cardiovascular event, and 146,139 matched controls were identified. LABA or LAMA use was measured in the year preceding the cardiovascular event and stratified by duration since initiation of LABA or LAMA treatment. Logistical regression was performed to estimate the odds ratios of CVD from LABA and LAMA treatment. New LABA use was associated with a 1.50-fold (95% confidence interval, 1.35-1.67; P less than .001) increased cardiovascular risk within 30 days of initiation, and new LAMA use was associated with a 1.52 fold (95% CI, 1.28-1.80; P less than .001) increased risk. In patients with prevalent LABA or LAMA use, the risk of CVD was absent or reduced.

Key limitations included the omission of contributors to cardiovascular disease, including smoking status and alcohol consumption, in the final analysis. Also, the contribution of worsening COPD to cardiovascular events was not accounted for.

Bottom line: Initiation of inhaled LABAs or LAMAs in patients with COPD is associated with a 1.5-fold increased risk of cardiovascular disease – including emergency or inpatient care for coronary artery disease, heart failure, ischemic stroke, or arrhythmia – in the first 30 days.

Citation: Wang MT et al. Association of cardiovascular risk with inhaled long-acting bronchodilators in patients with chronic obstructive pulmonary disease. JAMA Intern Med. 2018; 178(2):229-38.

Dr. Skinner is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

MADRID – Patients who are carriers of extended-spectrum beta lactamase–producing Enterobacteriaceae (ESBL-B) before colorectal surgery are at more than double the risk of surgical site infection, despite a standard prophylactic antibiotic regimen.

Surgical site infections (SSIs) occurred in 23% of those who tested positive for the pathogens preoperatively, compared with 10.5% of ESBL-B–negative patients – a significant increased risk of 2.25, Yehuda Carmeli, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual congress.

ESBL-B was not the infective pathogen in most infection cases, but being a carrier increased the likelihood of an ESBL-B SSI. ESBL-B was the pathogen in 7.2% of the carriers and 1.6% of the noncarriers. However, investigators are still working to determine if the species present in the wound infection are the same as the ones present at baseline, said Dr. Carmeli of Tel Aviv Medical Center.

CDC/James Arche/Illustrators: Alissa Eckert and Jennifer Oosthuizen

Michele G Sullivan/MDedge News

[email protected]

SOURCE: Carmeli et al, ECCMID 2018, Oral Abstract O1133.

MADRID – Patients who are carriers of extended-spectrum beta lactamase–producing Enterobacteriaceae (ESBL-B) before colorectal surgery are at more than double the risk of surgical site infection, despite a standard prophylactic antibiotic regimen.

Surgical site infections (SSIs) occurred in 23% of those who tested positive for the pathogens preoperatively, compared with 10.5% of ESBL-B–negative patients – a significant increased risk of 2.25, Yehuda Carmeli, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual congress.

ESBL-B was not the infective pathogen in most infection cases, but being a carrier increased the likelihood of an ESBL-B SSI. ESBL-B was the pathogen in 7.2% of the carriers and 1.6% of the noncarriers. However, investigators are still working to determine if the species present in the wound infection are the same as the ones present at baseline, said Dr. Carmeli of Tel Aviv Medical Center.

CDC/James Arche/Illustrators: Alissa Eckert and Jennifer Oosthuizen

Michele G Sullivan/MDedge News

[email protected]

SOURCE: Carmeli et al, ECCMID 2018, Oral Abstract O1133.

MADRID – Patients who are carriers of extended-spectrum beta lactamase–producing Enterobacteriaceae (ESBL-B) before colorectal surgery are at more than double the risk of surgical site infection, despite a standard prophylactic antibiotic regimen.

Surgical site infections (SSIs) occurred in 23% of those who tested positive for the pathogens preoperatively, compared with 10.5% of ESBL-B–negative patients – a significant increased risk of 2.25, Yehuda Carmeli, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual congress.

ESBL-B was not the infective pathogen in most infection cases, but being a carrier increased the likelihood of an ESBL-B SSI. ESBL-B was the pathogen in 7.2% of the carriers and 1.6% of the noncarriers. However, investigators are still working to determine if the species present in the wound infection are the same as the ones present at baseline, said Dr. Carmeli of Tel Aviv Medical Center.

CDC/James Arche/Illustrators: Alissa Eckert and Jennifer Oosthuizen

Michele G Sullivan/MDedge News

[email protected]

SOURCE: Carmeli et al, ECCMID 2018, Oral Abstract O1133.

Darrin Klimek/Thinkstock

Like everyone in the arc of social media impact, I was shocked and terribly saddened by the recent suicides of two New York women in medicine – a final-year medical student on May 1 and a second-year resident on May 5. As a specialist in physician health, a former training director, a long-standing member of our institution’s medical student admissions committee, and the ombudsman for our medical students, I am finding these tragedies harder and harder to reconcile. Something isn’t working. But before I get to that, what follows is a bulleted list of some events of the past couple of weeks that may give a context for my statements and have informed my two recommendations.

• May 3, 2018: I give an invited GI grand rounds on stress, burnout, depression, and suicide in physicians. The residents are quiet and say nothing. Faculty members seem only concerned about preventing and eradicating burnout – and not that interested in anything more severe.
• May 5: A psychiatry resident from Melbourne arrives to spend 10 days with me to do an elective in physician health. As in the United States, there is a significant suicide death rate in medical students and residents Down Under. In the afternoon, I present a paper at the annual meeting of the American Academy of Psychodynamic Psychiatry and Psychoanalysis on the use of psychotherapy in treatment-resistant suicidal depression in physicians. There is increasing hope that this essential modality of care will return to the contemporary psychiatrist’s toolbox.
• May 6: At the annual meeting of the American Psychiatric Association in New York, I’m the discussant for powerful heartfelt papers of five psychiatrists (mostly early career psychiatrists and one resident) that talked about living with a psychiatric illness. The audience is huge, and we hear narratives about internal stigma, self-disclosure, external stigma, shunning, bullying, acceptance, rejection, alienation, connection, and love by peers and family. The authenticity and valor of the speakers create an atmosphere of safety, which enables psychiatrists in attendance from all over the world to share their personal stories – some at the microphone, some privately.
• May 7: Again at the APA, I chair and facilitate a workshop on physician suicide. We hear from four speakers, all women, who have lost a loved one to suicide – a husband, a father, a brother, a son – all doctors. Two of the speakers are psychiatrists. The stories are gripping, detailed, and tender. Yes, the atmosphere is very sad, but there is not a pall. We learn how these doctors lived, not just how they died. They all loved medicine; they were creative; they cared deeply; they suffered silently; and with shame, they lost hope. Again, a big audience of psychiatrists, many of whom share their own stories, that they, too, had lost a physician son, wife, or mother to suicide. Some of their deceased family members fell through the cracks and did not receive the life-saving care they deserved; some, fearing assaults to their medical license, hospital privileges, or insurance, refused to see anyone. They died untreated.
• May 8: Still at the APA, a psychiatrist colleague and I collaborate on a clinical case conference. Each of us describes losing a physician patient to suicide. We walk the attendees through the clinical details of assessment, treatment, and the aftermath of their deaths. We talk openly and frankly about our feelings, grief, outreach to colleagues and the family, and our own personal journeys of learning, growth, and healing. The clinician audience members give constructive feedback, and some share their own stories of losing patients to suicide. Like the day before, some psychiatrists are grieving the loss of a physician son or sibling to suicide. As mental health professionals, they suffer from an additional layer of failure and guilt that a loved one died “under their watch.”
• May 8: I rush across the Javits Center to catch the discussant for a concurrent symposium on physician burnout and depression. She foregoes any prepared remarks to share her previous 48 hours with the audience. She is the training director of the program that lost the second-year resident on May 5. She did not learn of the death until 24 hours later. We are all on the edge of our seats as we listen to this grieving, courageous woman, a seasoned psychiatrist and educator, who has been blindsided by this tragedy. She has not slept. She called all of her residents and broke the news personally as best she could. Aided by “After A Suicide: A Toolkit for Residency/Fellowship Programs” (American Foundation for Suicide Prevention), she and her colleagues instituted a plan of action and worked with administration and faculty. Her strength and commitment to the well-being of her trainees is palpable and magnanimous. When the session ends, many of us stand in line to give her a hug. It is a stark reminder of how many lives are affected when someone you know or care about takes his/her own life – and how, in the house of medicine, medical students and residents really are part of an institutional family.
• May 10: I facilitate a meeting of our 12 second-year residents, many of whom knew of or had met the resident who died. Almost everyone speaks, shares their feelings, poses questions, and calls for answers and change. There is disbelief, sadness, confusion, some guilt, and lots of anger. Also a feeling of disillusionment or paradox about the field of psychiatry: “Of all branches of medicine, shouldn’t residents who are struggling with psychiatric issues feel safe, protected, cared for in psychiatry?” There is also a feeling of lip service being paid to personal treatment, as in quoted statements: “By all means, get treatment for your issues, but don’t let it encroach on your duty hours” or “It’s good you’re getting help, but do you still have to go weekly?”

In the immediate aftermath of suicide, feelings run high, as they should. But rather than wait it out – and fearing a return to “business as usual” – let me make only two suggestions:

Dr. Myers is a professor of clinical psychiatry at State University of New York, Brooklyn, and the author of “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.”
 

Darrin Klimek/Thinkstock

Like everyone in the arc of social media impact, I was shocked and terribly saddened by the recent suicides of two New York women in medicine – a final-year medical student on May 1 and a second-year resident on May 5. As a specialist in physician health, a former training director, a long-standing member of our institution’s medical student admissions committee, and the ombudsman for our medical students, I am finding these tragedies harder and harder to reconcile. Something isn’t working. But before I get to that, what follows is a bulleted list of some events of the past couple of weeks that may give a context for my statements and have informed my two recommendations.

• May 3, 2018: I give an invited GI grand rounds on stress, burnout, depression, and suicide in physicians. The residents are quiet and say nothing. Faculty members seem only concerned about preventing and eradicating burnout – and not that interested in anything more severe.
• May 5: A psychiatry resident from Melbourne arrives to spend 10 days with me to do an elective in physician health. As in the United States, there is a significant suicide death rate in medical students and residents Down Under. In the afternoon, I present a paper at the annual meeting of the American Academy of Psychodynamic Psychiatry and Psychoanalysis on the use of psychotherapy in treatment-resistant suicidal depression in physicians. There is increasing hope that this essential modality of care will return to the contemporary psychiatrist’s toolbox.
• May 6: At the annual meeting of the American Psychiatric Association in New York, I’m the discussant for powerful heartfelt papers of five psychiatrists (mostly early career psychiatrists and one resident) that talked about living with a psychiatric illness. The audience is huge, and we hear narratives about internal stigma, self-disclosure, external stigma, shunning, bullying, acceptance, rejection, alienation, connection, and love by peers and family. The authenticity and valor of the speakers create an atmosphere of safety, which enables psychiatrists in attendance from all over the world to share their personal stories – some at the microphone, some privately.
• May 7: Again at the APA, I chair and facilitate a workshop on physician suicide. We hear from four speakers, all women, who have lost a loved one to suicide – a husband, a father, a brother, a son – all doctors. Two of the speakers are psychiatrists. The stories are gripping, detailed, and tender. Yes, the atmosphere is very sad, but there is not a pall. We learn how these doctors lived, not just how they died. They all loved medicine; they were creative; they cared deeply; they suffered silently; and with shame, they lost hope. Again, a big audience of psychiatrists, many of whom share their own stories, that they, too, had lost a physician son, wife, or mother to suicide. Some of their deceased family members fell through the cracks and did not receive the life-saving care they deserved; some, fearing assaults to their medical license, hospital privileges, or insurance, refused to see anyone. They died untreated.
• May 8: Still at the APA, a psychiatrist colleague and I collaborate on a clinical case conference. Each of us describes losing a physician patient to suicide. We walk the attendees through the clinical details of assessment, treatment, and the aftermath of their deaths. We talk openly and frankly about our feelings, grief, outreach to colleagues and the family, and our own personal journeys of learning, growth, and healing. The clinician audience members give constructive feedback, and some share their own stories of losing patients to suicide. Like the day before, some psychiatrists are grieving the loss of a physician son or sibling to suicide. As mental health professionals, they suffer from an additional layer of failure and guilt that a loved one died “under their watch.”
• May 8: I rush across the Javits Center to catch the discussant for a concurrent symposium on physician burnout and depression. She foregoes any prepared remarks to share her previous 48 hours with the audience. She is the training director of the program that lost the second-year resident on May 5. She did not learn of the death until 24 hours later. We are all on the edge of our seats as we listen to this grieving, courageous woman, a seasoned psychiatrist and educator, who has been blindsided by this tragedy. She has not slept. She called all of her residents and broke the news personally as best she could. Aided by “After A Suicide: A Toolkit for Residency/Fellowship Programs” (American Foundation for Suicide Prevention), she and her colleagues instituted a plan of action and worked with administration and faculty. Her strength and commitment to the well-being of her trainees is palpable and magnanimous. When the session ends, many of us stand in line to give her a hug. It is a stark reminder of how many lives are affected when someone you know or care about takes his/her own life – and how, in the house of medicine, medical students and residents really are part of an institutional family.
• May 10: I facilitate a meeting of our 12 second-year residents, many of whom knew of or had met the resident who died. Almost everyone speaks, shares their feelings, poses questions, and calls for answers and change. There is disbelief, sadness, confusion, some guilt, and lots of anger. Also a feeling of disillusionment or paradox about the field of psychiatry: “Of all branches of medicine, shouldn’t residents who are struggling with psychiatric issues feel safe, protected, cared for in psychiatry?” There is also a feeling of lip service being paid to personal treatment, as in quoted statements: “By all means, get treatment for your issues, but don’t let it encroach on your duty hours” or “It’s good you’re getting help, but do you still have to go weekly?”

In the immediate aftermath of suicide, feelings run high, as they should. But rather than wait it out – and fearing a return to “business as usual” – let me make only two suggestions:

Dr. Myers is a professor of clinical psychiatry at State University of New York, Brooklyn, and the author of “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.”
 

Darrin Klimek/Thinkstock

Like everyone in the arc of social media impact, I was shocked and terribly saddened by the recent suicides of two New York women in medicine – a final-year medical student on May 1 and a second-year resident on May 5. As a specialist in physician health, a former training director, a long-standing member of our institution’s medical student admissions committee, and the ombudsman for our medical students, I am finding these tragedies harder and harder to reconcile. Something isn’t working. But before I get to that, what follows is a bulleted list of some events of the past couple of weeks that may give a context for my statements and have informed my two recommendations.

• May 3, 2018: I give an invited GI grand rounds on stress, burnout, depression, and suicide in physicians. The residents are quiet and say nothing. Faculty members seem only concerned about preventing and eradicating burnout – and not that interested in anything more severe.
• May 5: A psychiatry resident from Melbourne arrives to spend 10 days with me to do an elective in physician health. As in the United States, there is a significant suicide death rate in medical students and residents Down Under. In the afternoon, I present a paper at the annual meeting of the American Academy of Psychodynamic Psychiatry and Psychoanalysis on the use of psychotherapy in treatment-resistant suicidal depression in physicians. There is increasing hope that this essential modality of care will return to the contemporary psychiatrist’s toolbox.
• May 6: At the annual meeting of the American Psychiatric Association in New York, I’m the discussant for powerful heartfelt papers of five psychiatrists (mostly early career psychiatrists and one resident) that talked about living with a psychiatric illness. The audience is huge, and we hear narratives about internal stigma, self-disclosure, external stigma, shunning, bullying, acceptance, rejection, alienation, connection, and love by peers and family. The authenticity and valor of the speakers create an atmosphere of safety, which enables psychiatrists in attendance from all over the world to share their personal stories – some at the microphone, some privately.
• May 7: Again at the APA, I chair and facilitate a workshop on physician suicide. We hear from four speakers, all women, who have lost a loved one to suicide – a husband, a father, a brother, a son – all doctors. Two of the speakers are psychiatrists. The stories are gripping, detailed, and tender. Yes, the atmosphere is very sad, but there is not a pall. We learn how these doctors lived, not just how they died. They all loved medicine; they were creative; they cared deeply; they suffered silently; and with shame, they lost hope. Again, a big audience of psychiatrists, many of whom share their own stories, that they, too, had lost a physician son, wife, or mother to suicide. Some of their deceased family members fell through the cracks and did not receive the life-saving care they deserved; some, fearing assaults to their medical license, hospital privileges, or insurance, refused to see anyone. They died untreated.
• May 8: Still at the APA, a psychiatrist colleague and I collaborate on a clinical case conference. Each of us describes losing a physician patient to suicide. We walk the attendees through the clinical details of assessment, treatment, and the aftermath of their deaths. We talk openly and frankly about our feelings, grief, outreach to colleagues and the family, and our own personal journeys of learning, growth, and healing. The clinician audience members give constructive feedback, and some share their own stories of losing patients to suicide. Like the day before, some psychiatrists are grieving the loss of a physician son or sibling to suicide. As mental health professionals, they suffer from an additional layer of failure and guilt that a loved one died “under their watch.”
• May 8: I rush across the Javits Center to catch the discussant for a concurrent symposium on physician burnout and depression. She foregoes any prepared remarks to share her previous 48 hours with the audience. She is the training director of the program that lost the second-year resident on May 5. She did not learn of the death until 24 hours later. We are all on the edge of our seats as we listen to this grieving, courageous woman, a seasoned psychiatrist and educator, who has been blindsided by this tragedy. She has not slept. She called all of her residents and broke the news personally as best she could. Aided by “After A Suicide: A Toolkit for Residency/Fellowship Programs” (American Foundation for Suicide Prevention), she and her colleagues instituted a plan of action and worked with administration and faculty. Her strength and commitment to the well-being of her trainees is palpable and magnanimous. When the session ends, many of us stand in line to give her a hug. It is a stark reminder of how many lives are affected when someone you know or care about takes his/her own life – and how, in the house of medicine, medical students and residents really are part of an institutional family.
• May 10: I facilitate a meeting of our 12 second-year residents, many of whom knew of or had met the resident who died. Almost everyone speaks, shares their feelings, poses questions, and calls for answers and change. There is disbelief, sadness, confusion, some guilt, and lots of anger. Also a feeling of disillusionment or paradox about the field of psychiatry: “Of all branches of medicine, shouldn’t residents who are struggling with psychiatric issues feel safe, protected, cared for in psychiatry?” There is also a feeling of lip service being paid to personal treatment, as in quoted statements: “By all means, get treatment for your issues, but don’t let it encroach on your duty hours” or “It’s good you’re getting help, but do you still have to go weekly?”

In the immediate aftermath of suicide, feelings run high, as they should. But rather than wait it out – and fearing a return to “business as usual” – let me make only two suggestions:

Dr. Myers is a professor of clinical psychiatry at State University of New York, Brooklyn, and the author of “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.”
 

TORONTO – Among infants up to 60 days old with an invasive bacterial infection, adverse outcomes are associated with prematurity, ill appearance, and bacterial meningitis, a multicenter retrospective analysis found.

“Young infants are susceptible to serious bacterial infections, particularly when they’re less than 60 days of age,” Christopher Pruitt, MD, said at the annual Pediatric Academic Societies meeting. “Among these infants, bacteremia and bacterial meningitis, also referred to as invasive bacterial infections, are associated with higher rates of morbidity and mortality.”

Doug Brunk/MDedge News

Of the 442 infants included in the final analysis, the majority (80%) had bacteremia, 14% had bacterial meningitis plus bacteremia, and 6% had bacterial meningitis only. “For purposes of this study, patients with bacterial meningitis with or without bacteremia were categorized as having bacterial meningitis,” Dr. Pruitt said. He and his associates found that 14.5% of infants had one or more adverse outcomes. Adverse outcomes occurred in 39% of infants with bacterial meningitis, compared with 8.2% of infants with isolated bacteremia. Need for mechanical ventilation, vasoactive medications, and neurologic disability also was more common among infants with bacterial meningitis than it was among children with isolated bacteremia. There were 10 deaths overall, which amounted to about 2% in both groups.

On multivariate analysis, the rate of adverse outcomes was significantly higher for patients with bacterial meningitis than it was for those with isolated bacteremia (adjusted odds ratio, 8.8), for premature versus term infants (AOR, 5.9), for infants who were ill appearing versus non-ill appearing (AOR, 3.9), and for infants with no fever versus those with fever (AOR, 2.4). No significant associations with 30-day adverse outcomes were seen in patients with a complex chronic condition, compared with those without a complex chronic condition (AOR, 2.0), nor in the those aged 29-60 days versus those younger than 29 days (15% vs. 14%, respectively; AOR 0.7).

“When looking at the most common scenario – a full-term infant without an ill appearance, and bacteremia as opposed to bacterial meningitis – 3 of these 219 infants, or 1.4%, had an adverse outcome,” said Dr. Pruitt, who cares for patients in the ED at Children’s of Alabama in Birmingham. “And there were no deaths.” He also reported that 12 infants with invasive bacterial infections were discharged from the index ED visit without antimicrobial treatment. All had bacteremia and none had an adverse outcome.

Dr. Pruitt acknowledged certain limitations of the study, including its retrospective design, that the outcomes were limited to 30 days, and the fact that the findings may not be generalizable to nontertiary settings. “Our findings have important implications for the care of infants with invasive bacterial infections,” he concluded. “In particular, the high rate of adverse outcomes for infants with bacterial meningitis can provide some context for clinicians in assessing the need for diagnostic evaluation for invasive bacterial infection and discussing testing and treatment with parents. Our findings may also help to inform inpatient management for hospitalized infants with invasive bacterial infections, as well as anticipatory guidance for parents, particularly around follow-up. Further prospective studies evaluating the long-term outcomes of infants with invasive bacterial infections are needed.”

The study was supported in part by a grant from the National Institutes of Health. Dr. Pruitt reported having no financial disclosures.

[email protected]

TORONTO – Among infants up to 60 days old with an invasive bacterial infection, adverse outcomes are associated with prematurity, ill appearance, and bacterial meningitis, a multicenter retrospective analysis found.

“Young infants are susceptible to serious bacterial infections, particularly when they’re less than 60 days of age,” Christopher Pruitt, MD, said at the annual Pediatric Academic Societies meeting. “Among these infants, bacteremia and bacterial meningitis, also referred to as invasive bacterial infections, are associated with higher rates of morbidity and mortality.”

Doug Brunk/MDedge News

Of the 442 infants included in the final analysis, the majority (80%) had bacteremia, 14% had bacterial meningitis plus bacteremia, and 6% had bacterial meningitis only. “For purposes of this study, patients with bacterial meningitis with or without bacteremia were categorized as having bacterial meningitis,” Dr. Pruitt said. He and his associates found that 14.5% of infants had one or more adverse outcomes. Adverse outcomes occurred in 39% of infants with bacterial meningitis, compared with 8.2% of infants with isolated bacteremia. Need for mechanical ventilation, vasoactive medications, and neurologic disability also was more common among infants with bacterial meningitis than it was among children with isolated bacteremia. There were 10 deaths overall, which amounted to about 2% in both groups.

On multivariate analysis, the rate of adverse outcomes was significantly higher for patients with bacterial meningitis than it was for those with isolated bacteremia (adjusted odds ratio, 8.8), for premature versus term infants (AOR, 5.9), for infants who were ill appearing versus non-ill appearing (AOR, 3.9), and for infants with no fever versus those with fever (AOR, 2.4). No significant associations with 30-day adverse outcomes were seen in patients with a complex chronic condition, compared with those without a complex chronic condition (AOR, 2.0), nor in the those aged 29-60 days versus those younger than 29 days (15% vs. 14%, respectively; AOR 0.7).

“When looking at the most common scenario – a full-term infant without an ill appearance, and bacteremia as opposed to bacterial meningitis – 3 of these 219 infants, or 1.4%, had an adverse outcome,” said Dr. Pruitt, who cares for patients in the ED at Children’s of Alabama in Birmingham. “And there were no deaths.” He also reported that 12 infants with invasive bacterial infections were discharged from the index ED visit without antimicrobial treatment. All had bacteremia and none had an adverse outcome.

Dr. Pruitt acknowledged certain limitations of the study, including its retrospective design, that the outcomes were limited to 30 days, and the fact that the findings may not be generalizable to nontertiary settings. “Our findings have important implications for the care of infants with invasive bacterial infections,” he concluded. “In particular, the high rate of adverse outcomes for infants with bacterial meningitis can provide some context for clinicians in assessing the need for diagnostic evaluation for invasive bacterial infection and discussing testing and treatment with parents. Our findings may also help to inform inpatient management for hospitalized infants with invasive bacterial infections, as well as anticipatory guidance for parents, particularly around follow-up. Further prospective studies evaluating the long-term outcomes of infants with invasive bacterial infections are needed.”

The study was supported in part by a grant from the National Institutes of Health. Dr. Pruitt reported having no financial disclosures.

[email protected]

TORONTO – Among infants up to 60 days old with an invasive bacterial infection, adverse outcomes are associated with prematurity, ill appearance, and bacterial meningitis, a multicenter retrospective analysis found.

“Young infants are susceptible to serious bacterial infections, particularly when they’re less than 60 days of age,” Christopher Pruitt, MD, said at the annual Pediatric Academic Societies meeting. “Among these infants, bacteremia and bacterial meningitis, also referred to as invasive bacterial infections, are associated with higher rates of morbidity and mortality.”

Doug Brunk/MDedge News

Of the 442 infants included in the final analysis, the majority (80%) had bacteremia, 14% had bacterial meningitis plus bacteremia, and 6% had bacterial meningitis only. “For purposes of this study, patients with bacterial meningitis with or without bacteremia were categorized as having bacterial meningitis,” Dr. Pruitt said. He and his associates found that 14.5% of infants had one or more adverse outcomes. Adverse outcomes occurred in 39% of infants with bacterial meningitis, compared with 8.2% of infants with isolated bacteremia. Need for mechanical ventilation, vasoactive medications, and neurologic disability also was more common among infants with bacterial meningitis than it was among children with isolated bacteremia. There were 10 deaths overall, which amounted to about 2% in both groups.

On multivariate analysis, the rate of adverse outcomes was significantly higher for patients with bacterial meningitis than it was for those with isolated bacteremia (adjusted odds ratio, 8.8), for premature versus term infants (AOR, 5.9), for infants who were ill appearing versus non-ill appearing (AOR, 3.9), and for infants with no fever versus those with fever (AOR, 2.4). No significant associations with 30-day adverse outcomes were seen in patients with a complex chronic condition, compared with those without a complex chronic condition (AOR, 2.0), nor in the those aged 29-60 days versus those younger than 29 days (15% vs. 14%, respectively; AOR 0.7).

“When looking at the most common scenario – a full-term infant without an ill appearance, and bacteremia as opposed to bacterial meningitis – 3 of these 219 infants, or 1.4%, had an adverse outcome,” said Dr. Pruitt, who cares for patients in the ED at Children’s of Alabama in Birmingham. “And there were no deaths.” He also reported that 12 infants with invasive bacterial infections were discharged from the index ED visit without antimicrobial treatment. All had bacteremia and none had an adverse outcome.

Dr. Pruitt acknowledged certain limitations of the study, including its retrospective design, that the outcomes were limited to 30 days, and the fact that the findings may not be generalizable to nontertiary settings. “Our findings have important implications for the care of infants with invasive bacterial infections,” he concluded. “In particular, the high rate of adverse outcomes for infants with bacterial meningitis can provide some context for clinicians in assessing the need for diagnostic evaluation for invasive bacterial infection and discussing testing and treatment with parents. Our findings may also help to inform inpatient management for hospitalized infants with invasive bacterial infections, as well as anticipatory guidance for parents, particularly around follow-up. Further prospective studies evaluating the long-term outcomes of infants with invasive bacterial infections are needed.”

The study was supported in part by a grant from the National Institutes of Health. Dr. Pruitt reported having no financial disclosures.

[email protected]

Background: Antibiotic use is associated with an increased risk of C. difficile infection. Multiple studies have investigated the effects of probiotics in reducing the risk of C. difficile infection with varied results. This meta-analysis aims to assess the efficacy and safety of probiotics in reducing the risk of CDAD in patients taking antibiotics.

Study design: Meta-analysis.

Setting: A comprehensive electronic search for randomized, controlled trials investigating probiotics for prevention of CDAD or C. difficile infection were considered for inclusion. There were no language, publication status, or date limits applied.

Synopsis: This meta-analysis included 31 trials (8,672 participants) evaluating the relationship between probiotics and CDAD. The outcomes were pooled using a random effects model to calculate risk ratios and 95% confidence intervals. A complete case analysis suggested that probiotics reduce the risk of CDAD by 60% (1.5% vs. 4.0%; relative risk, 0.40; 95% confidence interval, 0.3-0.52), although a post-hoc subgroup analysis showed a statistically significant benefit only among patients with a high CDAD baseline risk (greater than 5%). Adverse events were assessed in 32 trials (8,305 participants), and the pooled analysis indicated that probiotic use reduced the risk of adverse events by 17% (RR, 0.83; 95% CI, 0.71-0.97).

Limitations to this meta-analysis include missing data from patients lost to follow-up and lack of success in testing all fecal samples. Lastly, that the strongest data for the beneficial effects of probiotics were demonstrated in patients with a high baseline risk of developing CDAD limits the study’s applicability to the general population.

Bottom line: Probiotic use in immunocompetent patients undergoing treatment with antibiotics decreases the incidence of CDAD without an increase in adverse events.

Citation: Goldenberg JZ et al. Probiotics for the prevention of Clostridium difficile–associated diarrhea in adults and children. Cochrane Database Syst Rev. 2017. doi: 10.1002/14651858.CD006095.pub4.

Dr. Skinner is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Antibiotic use is associated with an increased risk of C. difficile infection. Multiple studies have investigated the effects of probiotics in reducing the risk of C. difficile infection with varied results. This meta-analysis aims to assess the efficacy and safety of probiotics in reducing the risk of CDAD in patients taking antibiotics.

Study design: Meta-analysis.

Setting: A comprehensive electronic search for randomized, controlled trials investigating probiotics for prevention of CDAD or C. difficile infection were considered for inclusion. There were no language, publication status, or date limits applied.

Synopsis: This meta-analysis included 31 trials (8,672 participants) evaluating the relationship between probiotics and CDAD. The outcomes were pooled using a random effects model to calculate risk ratios and 95% confidence intervals. A complete case analysis suggested that probiotics reduce the risk of CDAD by 60% (1.5% vs. 4.0%; relative risk, 0.40; 95% confidence interval, 0.3-0.52), although a post-hoc subgroup analysis showed a statistically significant benefit only among patients with a high CDAD baseline risk (greater than 5%). Adverse events were assessed in 32 trials (8,305 participants), and the pooled analysis indicated that probiotic use reduced the risk of adverse events by 17% (RR, 0.83; 95% CI, 0.71-0.97).

Limitations to this meta-analysis include missing data from patients lost to follow-up and lack of success in testing all fecal samples. Lastly, that the strongest data for the beneficial effects of probiotics were demonstrated in patients with a high baseline risk of developing CDAD limits the study’s applicability to the general population.

Bottom line: Probiotic use in immunocompetent patients undergoing treatment with antibiotics decreases the incidence of CDAD without an increase in adverse events.

Citation: Goldenberg JZ et al. Probiotics for the prevention of Clostridium difficile–associated diarrhea in adults and children. Cochrane Database Syst Rev. 2017. doi: 10.1002/14651858.CD006095.pub4.

Dr. Skinner is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Antibiotic use is associated with an increased risk of C. difficile infection. Multiple studies have investigated the effects of probiotics in reducing the risk of C. difficile infection with varied results. This meta-analysis aims to assess the efficacy and safety of probiotics in reducing the risk of CDAD in patients taking antibiotics.

Study design: Meta-analysis.

Setting: A comprehensive electronic search for randomized, controlled trials investigating probiotics for prevention of CDAD or C. difficile infection were considered for inclusion. There were no language, publication status, or date limits applied.

Synopsis: This meta-analysis included 31 trials (8,672 participants) evaluating the relationship between probiotics and CDAD. The outcomes were pooled using a random effects model to calculate risk ratios and 95% confidence intervals. A complete case analysis suggested that probiotics reduce the risk of CDAD by 60% (1.5% vs. 4.0%; relative risk, 0.40; 95% confidence interval, 0.3-0.52), although a post-hoc subgroup analysis showed a statistically significant benefit only among patients with a high CDAD baseline risk (greater than 5%). Adverse events were assessed in 32 trials (8,305 participants), and the pooled analysis indicated that probiotic use reduced the risk of adverse events by 17% (RR, 0.83; 95% CI, 0.71-0.97).

Limitations to this meta-analysis include missing data from patients lost to follow-up and lack of success in testing all fecal samples. Lastly, that the strongest data for the beneficial effects of probiotics were demonstrated in patients with a high baseline risk of developing CDAD limits the study’s applicability to the general population.

Bottom line: Probiotic use in immunocompetent patients undergoing treatment with antibiotics decreases the incidence of CDAD without an increase in adverse events.

Citation: Goldenberg JZ et al. Probiotics for the prevention of Clostridium difficile–associated diarrhea in adults and children. Cochrane Database Syst Rev. 2017. doi: 10.1002/14651858.CD006095.pub4.

Dr. Skinner is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.