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ACP HospitalistWeekly 6-17-09

Highlights

• Updated guidelines target diagnosis, treatment of catheter-related infections

Infectious disease

• New scoring system may provide simple tool for predicting VAP mortality

Critical care

• Assessment tools fare better than physician opinion for delirium diagnosis in the ICU

FDA update

• Injectable ibuprofen approved for hospital use
• Skin sanitizers recalled due to presence of bacteria
• Class 1 recall for certain Medtronic pacemakers

From ACP Hospitalist

• Suggest a colleague as a Top Hospitalist

From ACP Internist

• ACP Internist blog hosts Grand Rounds

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, MD

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Highlights

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Updated guidelines target diagnosis, treatment of catheter-related infections

The Infectious Diseases Society of America has issued updated guidelines for the diagnosis and management of intravascular catheter-related infections.

The guidelines, last updated in 2001, address when and how catheter and blood cultures should be done and recommend treatment strategies. Specific recommendations for managing infections include:

• Use vancomycin in settings with an elevated prevalence of methicillin-resistant Staphylococcus aureus;
• Use combination antibiotic therapy for multidrug-resistant gram-negative bacilli when catheter-related bloodstream infection (CRBSI) is suspected in patients who are neutropenic, severely ill with sepsis, or known to be colonized with such pathogens until culture data are available;
• Remove long-term catheters from patients with CRBSI associated with conditions including severe sepsis, suppurative thrombophlebitis, endocarditis, bloodstream infection that continues despite 72 hours of antimicrobial therapy to which the infecting microbes are susceptible, or infections due to Staphylococcus aureus, Pseudomonas aeruginosa, fungi, or mycobacteria;
• Remove short-term catheters from patients with CRBSI due to gram-negative bacilli, S. aureus, enterococci, fungi, and mycobacteria.

The guidelines make specific recommendations regarding antibiotic lock therapy; pathogen-specific treatment; management of suppurative thrombophlebitis and persistent bloodstream infection; and detection and management of an outbreak of CRBSI. The guidelines also address how to treat different subtypes of catheter-related infections, including:

• short-term peripheral venous catheters;
• nontunneled and long-term central venous catheters;
• implanted catheter-related infections (other than infections related to hemodialysis catheters);
• pediatric patients with catheter-related infections; and
• infections related to hemodialysis catheters.

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Infectious disease

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New scoring system may provide simple tool for predicting VAP mortality

A simple five-point scoring system may be as effective as an older tool in evaluating and predicting mortality in patients with ventilator-associated pneumonia (VAP), a recent study concluded.

The new scoring system, called IBMP-10, assigned one point to each of the following: presence of immunodeficiency; blood pressure <90 mm Hg (systolic) or <60 mm Hg (diastolic); multilobar infiltrates noted on a chest radiograph; platelet count <100,000/mm³; and duration of hospitalization before VAP onset of >10 days. Researchers found that the new system worked as well as the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which is traditionally used to predict mortality in patients with VAP. The results are reported in the July 1 Clinical Infectious Diseases.

Researchers concluded that if future studies validate their results, the IBMP-10 score may represent a simple tool to evaluate VAP severity and predict outcomes.

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Critical care

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Assessment tools fare better than physician opinion for delirium diagnosis in the ICU

Assessment tools are better for detecting delirium in the ICU than physicians' opinion alone, according to a recent study.

Researchers examined the value of three methods for detecting delirium in the ICU: the Confusion Assessment Method for the ICU (CAM-ICU), the Intensive Care Delirium Screening Checklist (ICDSC), and the opinion of the ICU physician. One hundred twenty-six patients from a single mixed medical/surgical ICU were evaluated over an eight-month period. Nurses administered the assessment tools, and the ICU physicians were asked whether they thought patients were delirious. A reference rater—a psychiatrist, geriatrician or neurologist—then used established criteria to diagnose delirium. The study results appear in the June Critical Care Medicine.

The CAM-ICU had superior sensitivity and negative predictive value compared with the ICDSC (64% vs. 43% and 83% vs. 75%, respectively), while the ICDSC had higher specificity and positive predictive value (95% vs. 88% and 82% vs. 72%, respectively). Physicians' opinion had a sensitivity of just 29% and a specificity of 96% compared with the diagnosis made by the reference rater. However, this poor performance, which was a composite of residents, fellows and intensivists, was mostly due to the inaccurate evaluations by the residents. When scored separately, the intensivists and fellows showed much better diagnostic capabilities (sensitivity, 63%; specificity, 100%; positive predictive value, 100%; negative predictive value, 72%).

The authors noted that evaluations of delirium were not always performed at the same time and that some patients were given psychoactive medications between evaluations, which may have affected the results. However, they concluded that formal tools for assessing delirium perform better than physician opinion, highlighting the need for standardized screening in the ICU setting.

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FDA update

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Injectable ibuprofen approved for hospital use

The FDA last week approved the first injectable form of ibuprofen (Caldolor) to treat pain and fever.

Caldolor can be administered in the hospital only. Doses of 400 mg to 800 mg, over 30 minutes, every six hours are approved for acute pain. For fever, a 400-mg dose of the drug can be administered over 30 minutes, followed by 400 mg every four to six hours, or 100 to 200 mg every four hours, as necessary.

In clinical trials, the most common adverse reactions to Caldolor were nausea, flatulence, vomiting and headache. The drug has also been associated with high blood pressure, serious skin reactions and serious allergic reactions.

Caldolor should be used with caution in patients with congestive heart failure or kidney impairment, those at risk for blood clots, and those with a history of ulcers or gastrointestinal bleeding, the FDA said. In these groups, the lowest effective dose should be used for the shortest time to reduce risk for serious adverse events.

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Skin sanitizers recalled due to presence of bacteria

Several brands of skin sanitizer and skin protectant made by Clarcon Biological Chemistry Laboratory Inc. are being recalled, as high levels of disease-causing bacteria were found in the products during recent inspection, an FDA press release said.

Some of the bacteria found in the analyzed samples can cause opportunistic infections of the skin and underlying tissues which may require medical attention, and/or result in permanent damage. This is of particular concern because the products are promoted as antimicrobial agents that claim to treat open wounds and damaged skin, and to protect against various infectious diseases, the FDA said.

Following are products affected by the recall: Citrushield Lotion, Dermasentials DermaBarrier, Dermassentials by Clarcon Antimicrobial Hand Sanitizer, Iron Fist Barrier Hand Treatment, Skin Shield Restaurant, Skin Shield Industrial, Skin Shield Beauty Salon Lotion, Total Skin Care Beauty and Total Skin Care Work. All products should be discarded.

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Class 1 recall for certain Medtronic pacemakers

A Class 1 recall is in effect for some Medtronic Kappa and Sigma pacemakers, which may fail due to a separation of wires that connect the electronic circuit to other pacemaker components, an FDA news release said.

Subject to recall are the Kappa Series 600/700/900 and Sigma Series 100/200/300. Patients with these models of Kappa and Sigma pacemakers should determine if their pacemaker is part of this recall by contacting Medtronic at 1-800-505-4636 or going to their Web site. About 21,000 pacemakers are affected by the recall, most of which have been implanted in patients for at least five years, the FDA said.

Patients with malfunctioning pacemakers may experience symptoms associated with abnormal heart rate, such as fainting or lightheadedness. In rare cases, pacemaker-dependent patients may experience serious injury or die.

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our second annual Top Hospitalists issue. We're looking for the hospitalists who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 13, 2009, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2009 issue.

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From ACP Internist

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ACP Internist blog hosts Grand Rounds

ACP Internist hosts Grand Rounds, a weekly summary of the best health blog posts on the Internet, including:

• The rise of celebrities as "medical experts" and the public health menace they pose
• What should doctors say when patients ask how often they’ve performed a procedure?
• Health care reform: bloggers have all the answers

Join us on our blog for our edition of the oldest and most popular medical blog "carnival" on the Internet.

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Cartoon caption contest

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Put words in our mouth

ACP InternistWeekly and ACP HospitalistWeekly want readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries by June 18. ACP staff will choose three finalists and post them in the June 24 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the July 1 edition of ACP HospitalistWeekly.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated