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ACP HospitalistWeekly 10-7-09

Highlights

• Influenza: masks, bacteria and vaccination effectiveness
• At-home treatment for heart failure matches hospital

COPD

• Three-point risk score predicts mortality in patients admitted for acute COPD

Infectious disease

• Catheter retention raises risk for recurrent staph infection

FDA update

• Heparin to be less potent
• Diabetes drugs get warning about pancreatitis

From the College

• Physician, immunize thyself

Cartoon caption contest

• And the winner is…

Physician editor: A. Scott Keller, FACP

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Highlights

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Influenza: masks, bacteria and vaccination effectiveness

A comparison of surgical masks and N95 respirators, reports of bacterial co-infections, and evaluations of the effectiveness of widespread vaccination were among the top news about influenza last week.

Surgical masks were about as efficacious as N95 respirators in preventing influenza infection among health care workers in a recent noninferiority randomized, controlled trial. More than 400 nurses in eight Ontario hospitals were assigned to wear either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season. Influenza infection was measured by polymerase chain reaction or a fourfold rise in hemagglutinin titers. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and 48 (22.9%) in the respirator group, an absolute risk difference of -0.73% (P=0.86). Of note, adherence was lower in the N95 group (87.5%) than in the surgical mask group (100%). Also, only about 30% of the nurses in either group had been vaccinated against influenza. The results were published online Oct. 1 by the Journal of the American Medical Association.

The level of protection provided by the two kinds of masks appears to be similar in routine health care settings, although the results cannot be generalized to higher-risk procedures producing aerosolization, the study authors concluded. Current CDC recommendations call for N95 respirators for all health care worker contacts with influenza patients, although the agency is now reviewing its guidelines. According to an accompanying editorial, the JAMA study will likely not resolve debate on the issue, and should not distract from other means to prevent influenza spread in health care facilities, including hand hygiene, staying home from work when sick and vaccination of health care workers.

Vaccination against pneumococcus could play a role in reducing mortality from H1N1 influenza, according to the CDC's Morbidity and Mortality Weekly Report. An analysis of specimens from 77 patients who died of the pandemic strain this summer revealed that 22 of them (29%) had concurrent bacterial infections. Ten of the patients had pneumococcus. In addition to highlighting the benefits of vaccination, the findings underscore the importance of managing influenza patients who might also have bacterial pneumonia with both empiric antibacterial therapy and antiviral medications, the CDC said. The agency also released a 2009-2010 Influenza Season Triage Algorithm to assist physicians and those under their supervision in identifying indicators of and responses to symptoms of influenza-like illness in adults.

In the latest issue of Annals of Internal Medicine, researchers used mathematical models of New York City to forecast the effectiveness and cost-effectiveness of vaccination and antivirals against the current H1N1 outbreak as well as a hypothetical pandemic of H5N1. In the case of an H5N1 pandemic, they concluded that expanded use of an adjuvanted vaccine would be most effective and cost-effective. As for H1N1 influenza, researchers found that earlier vaccination in October prevents more deaths and is more cost saving than vaccination in November. Complete vaccination coverage is not needed, and the pandemic would be shortened if only 40% of the population were vaccinated, although the results would depend on when the epidemic peaks.

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At-home treatment for heart failure matches hospital

Heart failure patients who were treated at home for acute decompensation of chronic heart failure (CHF) had similar outcomes to those admitted to the hospital, a new study found.

The Italian study was a randomized, controlled trial of the Geriatric Home Hospitalization Service, in which hospital professionals (including geriatricians, nurses, physiotherapists and a social worker and counselor) treated patients at their homes. The study participants were at least 75 years old and were admitted to the study hospital's emergency department for acute decompensation of CHF. They were then either admitted to the general medicine ward (n=53) or the hospital-at-home program (which included education for patients and families and frequent physician and nurse visits) (n=48).

The primary outcome, six-month mortality, was the same in the two groups, as was the number of hospital admissions during six-month follow-up. The patients treated at home had a longer mean time to their next admission (84.3 days vs. 69.8 days, P=0.02). The home group also showed improvements in depression, nutritional status and quality of life. Four of the home patients were transferred to the hospital during the study, but after discharge, all were at home, while 16% of the hospital group were discharged to long-term care facilities.

The study demonstrates that hospital-at-home care is a viable, efficacious alternative to hospitalization for acutely decompensated CHF, the study authors concluded. They noted that although the home patients were on average treated for longer than the inpatients, the mean total cost was lower for patients treated at home ($2,604 vs. $3,028). The study was published in the Sept. 28 Archives of Internal Medicine.

Despite its successes, wider dissemination of the hospital-at-home model is impeded by many factors, including Medicare reimbursements, hospital incentives, geriatrician shortages, and adaptability, according to an accompanying editorial that called for a broadening of the availability of these models and awareness campaigns to educate consumers about their benefits, since 46% of patients eligible for the study declined to be assigned to hospital-at-home care.

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COPD

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Three-point risk score predicts mortality in patients admitted for acute COPD

A simple risk scoring system may help predict the severity of acute exacerbations of chronic obstructive pulmonary disease (COPD) at admission, a new study found.

Researchers analyzed more than 88,000 patients admitted with acute exacerbations of COPD over two years and used recursive partition to create risk classifications for in-hospital mortality, with need for mechanical ventilation as a secondary endpoint. Three variables proved to be predictive of mortality: serum urea nitrogen level greater than 25 mg/dL, acute mental status change, and pulse greater than 109 beats per minute.

For patients with all three risk factors, the mortality rates were 13.1% and 14.6% in the derivation and validation cohorts, respectively, compared with 0.3% in both cohorts among patients who did not have the risk factors and were younger than 65 years. The area under the receiver-operating curve in the two cohorts was 0.72 and 0.71, respectively, for mortality, and 0.77 (both cohorts) for mechanical ventilation. The study appears in the Sept. 28 Archives of Internal Medicine.

The assessment tool may be especially valuable because it relies on information that is easily obtainable in the emergency department, the authors said. The existing assessment tool for COPD, the BODE score (body mass index, degree of airflow obstruction and dyspnea and exercise capacity), requires extensive assessment of many risk factors and is difficult to implement in the ED, they noted.

The authors acknowledged possible limitations of the study, including reliance on administrative data for diagnosis of acute exacerbations of COPD; exclusion of patients with a principal diagnosis of acute respiratory failure; and lack of information on certain COPD-specific covariates, especially forced expiratory volume in the first second of expiration. However, they emphasized that the goal of the study was to create a score that could be easily used with routinely available data.

The authors concluded that while no assessment tool is infallible, applying the risk score might enhance care of patients with acute exacerbations of COPD by predicting risk of death and need for mechanical ventilation.

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Infectious disease

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Catheter retention raises risk for recurrent staph infection

Retention of the central venous catheter (CVC) in patients with coagulase-negative staphylococcal bacteremia did not affect resolution of the infection but was a significant risk factor for recurrence, a recent study found.

Researchers retrospectively evaluated 188 patients with coagulase-negative staphylococcal bacteremia using CDC criteria of two positive blood cultures and found that resolution of infection within 48 hours of antimicrobial therapy occurred in 93% of patients and was not affected by CVC removal or exchange versus retention.

Using multiple logistic regression analysis, researchers found infections were less likely to resolve in patients with previous ICU stays and those who had other concurrent infection sites. Duration of therapy did not affect recurrence, but patients with catheter retention were 6.6 times more likely to have a recurrence than those who had catheters removed or exchanged. The study also found that infusion ports causing CVC-related infections were associated with recurrences. The findings appear in the Oct. 15 Clinical Infectious Diseases.

Infectious Disease Society of America guidelines recommend that systemic antibiotic therapy be prolonged to at least 10 days if a CVC is retained, the authors noted. However, data from this study show that prolonged treatment was not associated with better resolution of infection or significantly lower recurrence rate.

More research is needed to determine the efficacy of salvage interventions in cases where CVC removal is not possible, such as in patients with limited vascular access or thrombocytopenia, the authors said. Future studies should focus on the exchange of the CVC over guidewire for a new antimicrobial catheter or use of effective antimicrobial lock therapy in patients with non-exchangeable surgically implanted catheters.

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FDA update

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Heparin to be less potent

The FDA announced a change to the United States Pharmacopeia monograph for heparin, effective October 1. The change, which comes in response to the 2007-2008 heparin contamination, will lessen the potential for contamination of heparin and harmonize the USP unit dose with the WHO International Standard unit dose, according to an FDA alert.

The change will result in approximately a 10% reduction in the potency of the heparin marketed in the U.S. The decrease in potency may have clinical significance in some situations, such as when heparin is administered as a bolus intravenous dose and an immediate anticoagulant effect is clinically important. In such situations, clinicians should consider the change in potency when making decisions about what dose to administer, the FDA said. The change is expected to be less clinically significant when heparin is administered subcutaneously due to the low and highly variable bioavailability associated with this route. Also, more heparin may be required to achieve and maintain the desired level of anticoagulation in some patients.

Heparin manufactured to meet the old and new USP monograph will likely be available simultaneously, with potential differences in potency. Products using the new potency definition are anticipated to be available on or after October 8. The FDA is working with the manufacturers of heparin to ensure that an appropriate identifier is placed on heparin made under the new USP monograph. Most manufacturers will place an “N” next to the lot number.

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Diabetes drugs get warning about pancreatitis

Changes have been made to the prescribing information for sitagliptin (Januvia) and sitagliptin/metformin (Janumet) because of reports of acute pancreatitis, the FDA said last week.

Eighty-eight post-marketing cases of acute pancreatitis, including two cases of hemorrhagic or necrotizing pancreatitis in patients using sitagliptin, were reported to the agency between October 2006 and February 2009. It is recommended that health care professionals monitor patients carefully for the development of pancreatitis after initiation or dose increases of sitagliptin or sitagliptin/metformin, the FDA said. Also, it is not known if patients with a history of pancreatitis are at increased risk for further episodes, so these medications should be used with caution and with appropriate monitoring in such patients.

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From the College

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Physician, immunize thyself

Steven Weinberger, FACP, continues his monthly column for KevinMD.com, one of the Web's most influential medical blogs.

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by John P. Reed, FACP, of the Smithsburg Family Medical Center in Maryland. He is also our first repeat winner, having won the contest in April of this year. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 156 ballots online to choose the winning entry. Thanks to all who voted!

"Apparently, HIPAA now requires we keep personal health information from the patient as well."

The winning entry captured 59.6% of the votes.

The runners up were:

"We always cover the ears of the patient whenever we need to ask the nurse how to do something."
"As you may have surmised, palpation of the ears of a patient who presented with topical epoxy exposure is ill-advised."

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