In preparing for a presentation on important studies related to hospitalists/inpatients for a meeting of the Connecticut chapter of ACP, I looked for articles about common inpatient diseases and problems, like congestive heart failure (CHF), chronic obstructive pulmonary disease, and management of glycemic control. In the past year, guidelines for each of these problems were published.
Other recently published papers compared various diuretic regimens for CHF patients and the best ways to treat methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Finally, a recent paper on the role of health literacy in patients with CHF directly relates to an issue that is top-of-mind for many hospitalists: decreasing readmissions.
Here are some quick pearls on the seven studies I found compelling:
Managing glycemic control in inpatients
The main take-home from these guidelines by the American College of Physicians (ACP) is to avoid blood glucose targets less than 140 mg/dL for patients who aren't in the ICU. For patients in the surgical intensive care unit (SICU) and medical intensive care unit (MICU) on insulin therapy, the College recommends a target blood glucose level of 140-200 mg/dL. Intensive therapy to control blood glucose is not recommended in nonsurgical or surgical medical ICU patients, regardless of whether they have diabetes. The guidelines were published Feb. 15, 2011 in Annals of Internal Medicine.
Diagnosis and management of chronic obstructive pulmonary disease
Several recommendations emerged from these chronic obstructive pulmonary disease (COPD) guidelines by ACP and four other medical societies, which were published in the Aug. 2, 2011 Annals of Internal Medicine. They include the following:
- Use spirometry to diagnose airway obstruction only in patients with respiratory symptoms (Grade: strong recommendation, moderate-quality evidence).
- For stable COPD patients with respiratory symptoms and FEV1 between 60% and 80% predicted, inhaled bronchodilators may be used (Grade: weak recommendation, low-quality evidence).
- For stable COPD patients with respiratory symptoms and FEV1 <60% predicted, treat with inhaled bronchodilators (Grade: strong recommendation, moderate- quality evidence).
- Prescribe monotherapy with long-acting inhaled anticholinergics or inhaled β-agonists for symptomatic patients and FEV1 <60% predicted (Grade: strong recommendation, moderate-quality evidence).
- Consider combination inhaled therapies (long-acting anticholinergics, long-acting β-agonists, or inhaled steroids) for symptomatic patients with FEV1 <60% predicted (Grade: weak recommendation, moderate-quality evidence).
- Prescribe pulmonary rehabilitation for symptomatic patients and FEV1 <50% predicted (Grade: weak recommendation, moderate-quality evidence).
- Prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (PaO2 ≤55 mm Hg or SpO2 ≤ 88%) (Grade: strong recommendation, moderate-quality evidence).
Intravenous furosemide for acute decompensated heart failure
A study on 308 patients with acute decompensated heart failure found no difference between a high dose or low dose of IV furosemide nor between continuous or bolus therapy in terms of global assessment of symptoms. The low dose was the IV equivalent of a patient's daily oral dose of furosemide equivalents, while the high dose was 2.5 times a patient's daily oral dose of furosemide equivalents. Boluses were given every 12 hours. While patients who received high doses had greater diuresis, they were also more likely to have a transient rise in creatinine. The study was published in the March 3, 2011 New England Journal of Medicine.
Managing chronic heart failure
In summarizing the updated guidelines from the United Kingdom's National Institute for Health and Clinical Excellence (NICE) on managing heart failure, an Aug. 16, 2011 Annals of Internal Medicinearticle noted that patients should be monitored by using serial measurement of serum natriuretic peptide. It also emphasized that no therapy has been shown to be effective in heart failure with preserved ejection fraction and described the role of echocardiography and specialist assessment in diagnosing heart failure. Finally, the guidelines presented a pathway for pharmacologic treatment, rehabilitation, and pacing therapy (implantable cardioverter-defibrillator and cardiac resynchronization therapy) for patients with heart failure and left ventricular systolic dysfunction, and heart failure with preserved ejection fraction.
Heart failure, health literacy and outcomes
A retrospective cohort study of 1,494 outpatients with heart failure found that low health literacy was independently associated with higher mortality, although not with hospitalization. The study, in the April 27, 2011 Journal of the American Medical Association, drives home the overall importance of health literacy.
Fidaxomicin looks promising for C. diff.
A comparison of fidaxomicin and vancomycin for treating Clostridium difficile found that fidaxomicin did just as well in resolving symptoms and patients who took it were less likely to have recurrence. Patients in the study were randomly assigned to receive either 200 mg of fidaxomicin twice daily or 125 mg of vancomycin four times daily by mouth for 10 days. The study was published in the Feb. 3, 2011 New England Journal of Medicine.
MRSA treatment guidelines
The Infectious Diseases Society of America's guidelines for treating MRSA appeared in the Jan. 4, 2011 online issue of Clinical Infectious Diseases. They include the following:
- Incise and drain simple abscesses and boils. These are likely due to MRSA. For cutaneous abscesses that are associated with severe or extensive disease, are in difficult areas to drain (e.g., face, hand, genitalia), progress rapidly in the presence of associated cellulitis, don't respond to drainage, or involve signs and symptoms of systemic illness, use an antibiotic active against MRSA.
- For hospitalized patients with skin and soft tissue infections (including major abscesses, cellulitis, surgical wound infection and infected ulcers and burns), use surgical debridement and an antibiotic active against MRSA.
- The main antibiotics for MRSA in the hospitalized patient are vancomycin, linezolid (oral or IV), daptomycin, telavancin and clindamycin (oral or IV). In addition, oral trimethoprim/sulfamethoxazole and doxycycline are active against MRSA.
- Cellulitis that is non-purulent and is not associated with a boil is usually due to Streptococcus or methicillin-sensitive Staphylococcus aureus (MSSA). Usually initiate treatment with cefazolin, but change to antibiotics active against MRSA if there is no effect.