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ACP HospitalistWeekly 2-17-10

Highlights

• New guidelines for catheter-associated UTIs
• Larger, for-profit hospitals use feeding tubes more often in some patients

Thromboembolism

• Patients with superficial vein thrombosis may also have DVT
• Lower-than-standard dose of rt-PA just as effective for PTE

Mental health

• Proposed updates for DSM-5 released

FDA update

• Rosuvastatin approved for patients without heart disease
• AED, IV equipment recalled

Internal Medicine 2010

• ACP Job Placement Center calls for physician profiles

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

Highlights

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New guidelines for catheter-associated UTIs

New clinical practice guidelines for diagnosing, preventing and treating catheter-associated urinary tract infections (CA-UTIs) were released last week by the Infectious Diseases Society of America.

The guidelines, prepared by an IDSA expert panel, comprise diagnostic criteria, as well as strategies to reduce CA-UTI risk and manage patients with catheter-associated asymptomatic bacteriuria or symptomatic UTI. They also address strategies that haven't been found to reduce CA-UTIs. The guidelines are meant to be used by all physicians involved with direct patient care, especially in-hospital and long-term facility care. Recommendation strength is graded A, B and C (good, moderate and poor), and quality of evidence is I, II and III, with I being the strongest. The guidelines, published in the March 1 Clinical Infectious Diseases, include the following:

• Indwelling catheters should be removed as soon as they are no longer required to reduce the risk of CA-bacteriuria (A-I recommendation) and CA-UTI (A-II).
• In patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization, CA-UTI is defined by the presence of symptoms or signs compatible with UTI with no other identified source, along with at least 103 cfu/mL of at least one bacterial species in a single catheter urine specimen, or in a midstream voided urine specimen from a patient whose catheter has been removed within the previous 48 hours (A-III).
• In patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization, catheter-associated asymptomatic bacteriuria is defined by the presence of 10⁵ cfu/mL of 1 bacterial species in a single catheter urine specimen in a patient without symptoms compatible with UTI (A-III).
• Signs and symptoms compatible with CA-UTI include new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; and pelvic discomfort. Dysuria, urgent or frequent urination, or suprapubic pain or tenderness are suggestive of CA-UTI in those whose catheters have been removed (A-III).
• In the catheterized patient, pyuria is not diagnostic of CA-bacteriuria or CA-UTI (A-II).To limit unnecessary catheterization, indwelling catheters shouldn't be used to manage urinary incontinence, and should require a physician's order in the chart before placement (A-III).
• Systemic antimicrobial prophylaxis shouldn't be routinely used in patients with short-term (A-III) or long-term (A-II) catheterization—including patients who undergo surgical procedures—for the purpose of reducing CA-bacteriuria or CA-UTI.
• Prophylactic antimicrobials shouldn't be administered routinely to patients at the time of catheter placement to reduce CA-UTI (A-I) or at the time of catheter removal (B-I) or replacement (A-III) to reduce CA-bacteriuria.
• Seven days is the recommended duration of antimicrobial treatment for patients with CA-UTI who have prompt resolution of symptoms (A-III). Ten to 14 days of treatment is recommended for patients with a delayed response (A-III), whether the patient stays catheterized or not.

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Larger, for-profit hospitals use feeding tubes more often in some patients

Acute care hospitals that are larger, have greater ICU use, and operate for profit are more likely than other hospitals to insert feeding tubes in patients admitted from nursing homes with advanced cognitive impairment, a new study found.

Researchers studied 163,022 nursing home residents aged 66 years and older who had advanced cognitive impairment and had been admitted to at least one of 2,797 acute care hospitals between 2000 and 2007. To determine feeding tube placements, they took a 20% sample of all Medicare claims files; hospitals that had at least 30 of these admissions during the study period were included in the study. Bed size, ownership, urban location, and medical school affiliation were examined in relation to endoscopic or surgical insertion of a gastrostomy tube during hospitalization. Researchers also evaluated hospital care practices for chronically ill patients, including ICU use in the last six months of life, use of hospice, and ratio of specialists to primary care physicians. Results appeared in the Feb. 10 Journal of the American Medical Association.

For-profit hospitals had higher feeding tube insertion rates than government-owned hospitals (8.5 vs. 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% CI, 1.21 to 1.46). Hospitals with more than 310 beds also had more insertions than those with less than 101 beds (8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35 to 1.63), as did those with more ICU use in the last six months of life (highest vs. lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20 to 3.06). The differences remained after researchers adjusted for patient-level characteristics. About 12% of the hospitals didn't insert any feeding tubes; these tended to be smaller, located in rural regions and unaffiliated with a medical school. White nursing home residents had the lowest likelihood of feeding tube insertion, while black residents had an almost two-fold increase in the likelihood of feeding tube insertion (absolute difference in insertions per 100 admissions, 8.5; AOR, 1.96; 95% CI, 1.89 to 2.04).

Limitations of the study include the fact that information on physician counseling and patient preferences about feeding tube insertion was lacking, except for orders noted in the Minimum Data Set to forgo artificial hydration and nutrition, the authors noted. In addition, researchers relied on ICD-9 and CPT procedure codes to indicate whether a feeding tube was placed, and these data may not have been entirely accurate. While only a first step toward understanding feeding tube insertion practices, the findings suggest a need for interventions to ensure that the use of these tubes is in line with patients' wishes and reflects a clear discussion of risks and benefits, which often doesn't occur in nursing homes, the authors noted.

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Thromboembolism

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Patients with superficial vein thrombosis may also have DVT

Many patients who present with superficial venous thrombosis (SVT) also either have or soon develop venous thromboembolism (DVT), according to a new study.

The observational French study included 844 consecutive patients who saw a vascular medicine specialist for a symptomatic SVT of the lower limbs that was at least 5 cm on compression ultrasonography. At the first visit, 24.9% of the patients were found to also have a DVT or symptomatic pulmonary embolism. Over three months of follow-up, 10% of the remaining patients developed thromboembolic complications, even though 90% of them received anticoagulants.

Patients who were male, had a history of DVT or pulmonary embolism, had previous cancer, or no varicose veins—risk factors that have been noted by other studies—were at higher risk of complications during follow-up. This study was limited by a premature termination of enrollment with only about half the patients who were originally called for. The results were published in the Feb. 16 Annals of Internal Medicine.

The findings show that SVT is not entirely benign, study authors concluded. Clinicians should consider using compression ultrasonography in SVT patients as well as watching for symptoms of pulmonary embolism (and testing when symptoms are spotted) and following up closely with all of these patients, the researchers said. They also called for more research into the benefits and risks of using systemic anticoagulant therapy for symptomatic relief of SVT and to prevent DVT.

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Lower-than-standard dose of rt-PA just as effective for PTE

A lower dose of recombinant tissue-type plasminogen activator (rt-PA, alteplase) works as well as the standard dose in treating pulmonary thromboembolism (PTE), and may carry fewer risks, a new study found.

In a prospective, randomized, multicenter trial, Chinese researchers assigned 65 patients to receive 50 mg of rt-PA over two hours, and 53 patients to receive 100 mg over two hours. Patients had acute PTE and either hemodynamic instability or massive pulmonary artery obstruction and right ventricular dysfunction (RVD). Researchers measured efficacy by observing improvements in RVDs on echocardiograms, lung perfusion defects on ventilation perfusion lung scans, and pulmonary artery obstructions on CT angiograms. They also measured death, bleeding and PTE recurrence. Results were reported in the February Chest.

Patients in both groups saw similar improvements in right ventricular dysfunctions, lung perfusion defects, and pulmonary artery obstructions, regardless of whether they had hemodynamic instability or massive pulmonary artery obstruction. Six percent of patients (n=3) died in the 100 mg/2 h rt-PA group and 2% (n=1) died in the 50 mg/2 h rt-PA group due to PTE or bleeding. The 50 mg/2 h rt-PA patients with a body weight of less than 65 kg were significantly less likely to have bleeding episodes than the 100 mg/2 h patients of the same weight category (14.8% vs 41.2%, P=0.049). Neither group had fatal recurrent PTE.

Study limitations included a small sample size, and the fact that physicians treating patients were not blinded to the study. The study results emphasize the importance of finding the optimal rt-PA dose when treating patients with PTE, given the risk of bleeding with the treatment, the authors noted. An editorialist noted that imaging showed 11% of 50 mg patients deteriorated compared to 4% of 100 mg patients; skeptics may say that such worsening is the outcome to be most concerned with, the editorialist wrote. Still, while the results aren't definitive, physicians should consider using the 50 mg/2 h dose in lower-weight patients with PE who have hemodynamic compromise or another indication for thrombolysis, the editorialist said.

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Mental health

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Proposed updates for DSM-5 released

The American Psychiatric Association last week released proposed diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The revisions, which are open to public comment until April 20, were developed by 13 work groups and include changes such as:

• Elimination of the diagnostic category of substance dependence. Both substance abuse and dependence will fall under a new category of "addiction and related disorders."
• New suicide scales, which include research-based criteria, to help identify individuals most at risk.
• A new category of "behavioral addictions," in which gambling will be the only disorder. Internet addiction was consider for this category, but found to be insufficiently researched.
• A single category of "autism spectrum disorders" to include autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder.
• A change from the term "mental retardation" to "intellectual disability."
• A new "risk syndromes" category to identify earlier stages of mental disorders including dementia.
• Changes in definitions of some eating disorders to emphasize development in adults.
• Addition of "dimensional assessments" to diagnostic evaluations to take into account the severity of symptoms and cross-cutting symptoms (such as insomnia or anxiety) that occur across different diagnoses.

After public comments are collected, the new criteria will undergo review and refinement, including field trials, over the next two years. The changes can be viewed and comments submitted at the DSM-5 Web site. The final DSM-5 is expected to be released in May 2013, according to a press release. The last edition of the DSM was published in 1994.

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FDA update

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Rosuvastatin approved for patients without heart disease

Last week the FDA approved the cholesterol-lowering medication rosuvastatin (Crestor) for some patients who are at increased risk of heart disease but have not been diagnosed with it.

The drug is now approved for men 50 years of age and older and women 60 years of age and older who have an elevated level of high-sensitivity C-reactive protein (CRP) and at least one additional traditional cardiovascular risk factor such as smoking, high blood pressure, a family history of premature heart disease, or low amounts of HDL cholesterol.

The new indication is intended to reduce the likelihood of a heart attack or stroke or the need for a procedure to treat blocked or narrowed arteries in patients who have never been diagnosed with heart disease but are at increased risk of a cardiac event, according to an FDA press release. The approval, which was based on the results of the JUPITER trial, does not support use in patients who have an elevated high-sensitivity CRP but no traditional cardiovascular risk factors.

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AED, IV equipment recalled

The FDA announced recalls of automated external defibrillators and intravenous access devices last week.

Several AEDs have been recalled by manufacturer Cardiac Science Corp because the devices may not be able to deliver therapy during a cardiac resuscitation attempt. The affected machines were manufactured or serviced between Oct. 19, 2009 and Jan. 15, 2010 and include the following models: Powerheart 9300A, 9300E, 9300P, 9390A, 9390E, CardioVive 92532 and CardioLife 9200G and 9231. Each affected AED should immediately be removed from service since it may not deliver the expected therapy, the FDA said.

Certain lots of BD Q-Syte Luer Access Devices have been recalled because they may cause an air embolism or leakage of blood or therapeutic product, which may result in serious injury or death. The device, a needleless valve, is intended for use with other infusion therapy products in the administration of fluids into the intravenous system. The affected lots were distributed from November 2008 through November 2009.

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Internal Medicine 2010

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ACP Job Placement Center calls for physician profiles

Physicians looking for a new job may submit a profile online to the ACP Job Placement Center, a service available at Internal Medicine 2010 in Toronto, Canada. The center, located in the Metro Toronto Convention Centre’s Exhibit Hall, Booth 222, provides physicians with tools to assist in job searching as well as the opportunity to meet with potential employers.

Physician profiles are distributed to numerous employers participating in Internal Medicine 2010, which will be held April 22-24. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the Convention Centre.

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Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly wants 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 to acphospitalist@acponline.org. ACP staff will choose three finalists and post them online for a vote by readers. The winner will appear in an upcoming edition.

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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