ACP HospitalistWeekly 3-31-10
- Updated C. difficile guidelines address changes in disease strain, drug efficacy
- Studies examine ABCD2 score for stroke risk prediction
- French intervention reduced MRSA infections
- Program can help opioid-dependent inpatients transition to outpatient treatment
Cartoon caption contest
- And the winner is…
Physician editor: A. Scott Keller, FACP
Updated C. difficile guidelines address changes in disease strain, drug efficacy
Two professional societies have issued updated Clostridium difficile guidelines to address epidemiologic and treatment changes since guidelines were first released in 1995.
In the last 15 years, researchers have identified a more virulent strain of C. difficile and have published data on the decreased effectiveness of metronidazole in severe disease, said the update by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. The update was published in the May Infection Control and Hospital Epidemiology. Recommendations include:
- While stool culture is the most sensitive test, it is not clinically practical. Toxin testing is most important clinically, but lacks sensitivity. A potential strategy is to employ a two-step method that uses enzyme immunoassay detection of glutamate dehydrogenase (GDH) as initial screening, and then uses the cell cytotoxicity assay or toxigenic culture as the confirmatory test for GDH-positive stool specimens. Since results seem to differ based on the GDH kit used, this is an interim recommendation.
- Polymerase chain reaction (PCR) testing seems to be rapid, sensitive and specific, but more data are needed before it can be recommended for routine testing.
- Avoid repeat testing during the same episode of diarrhea; it has limited value.
- Use metronidazole for an initial episode of mild-to-moderate C. difficile infection (CDI). The dosage is 500 mg orally three times per day for 10 to 14 days.
- For an initial episode of severe CDI, use vancomycin. The dosage is 125 mg orally four times per day for 10 to 14 days.
- For the first recurrence of CDI, usually use the same regimen as the initial episode, though stratify by disease severity. For the second or later recurrence, use vancomycin with a tapered and/or pulse regimen. Don't use metronidazole after the first recurrence or for long-term chronic therapy, due to the potential for cumulative neurotoxicity.
- Health care workers and visitors must use gloves and gowns on entering the room of a patient with CDI. Emphasize hand hygiene compliance and contact precautions.
- If possible, give patients with CDI a private room. If this isn't possible, provide a dedicated toilet for each patient with CDI.
Studies examine ABCD2 score for stroke risk prediction
The ABCD2 score is useful for prediction of stroke severity and risk after transient ischemic attack (TIA), according to findings from two recent studies.
The ABCD2 score, which assesses age (A), blood pressure (B), clinical features (C), symptom duration and diabetes (D2) , was developed to predict stroke risk and determine appropriateness of hospital admission in patients with TIA.
In the first study, researchers in England examined the value of the ABCD2 score for predicting severity of recurrent events in 500 patients who had had TIA. Of these, 11% experienced a recurrent TIA and 10% had recurrent stroke within a week of the initial event, according to face-to-face interviews. The ABCD2 score had a high predictive value for major recurrent stroke and also predicted related variables such as disability and length of stay. However, it was weakly predictive of minor stroke and had an inverse relationship to the risk for recurrent TIA.
In the second study, researchers used data from the North Dublin TIA Study to determine the external validity of the ABCD2 score, carotid stenosis and atrial fibrillation as predictors of early recurrent stroke in 443 patients with confirmed TIA. Carotid stenosis was the best predictor of future events, but the ABCD2 score was useful for predicting recurrent events in patients whose TIA was suspected by nonspecialists. However, in stroke specialist-confirmed TIA cases, the ABCD2 score performed no better than chance alone for predicting stroke at 90 days, largely because some patients experienced recurrent stroke despite having low ABCD2 scores.
The authors of the first study acknowledged that their results were limited by the small number of stroke outcomes studied, among other factors, while the authors of the second study noted “too few” patients had early brain imaging, among other limitations. An accompanying editorial said that both studies emphasize the positive and negative aspects of the ABCD2 score. For example, while it is easy to use and provides information on both diagnosis and prognosis, it does not take brain imaging data or ultrasound data into account.
Nevertheless, "Despite its shortcomings, the ABCD2 score appears to be the best clinical tool available to stratify high-risk TIA patients and may assist in developing admission recommendations in cooperation among neurologists, internists, and emergency department physicians for patients presenting with TIAs," the editorialists wrote. They stressed, however, that the ABCD2 score should not substitute for individual clinical judgment.
Both studies and the editorial were published online March 18 by Stroke.
French intervention reduced MRSA infections
A multi-faceted intervention in French hospitals was associated with a decline in rates of methicillin-resistant Staphylococcus aureus (MRSA), a new study reported.
The 38 teaching hospitals (acute care, rehab and long-term care) instituted a MRSA-reduction program in 1993. The program included passive and active surveillance, quick notification of cases, barrier precautions, training and feedback. In 2001, a campaign to promote use of alcohol-based hand-rub solutions was added. The observational study calculated MRSA burden in the hospitals by measuring the proportion of S. aureus strains that showed methicillin resistance and the incidence of MRSA cases.
Overall, the hospitals had about a 35% decrease in MRSA burden from 1993 to 2007. Incidence went down from 0.86 to 0.56 per 1,000 hospital days. The MRSA burden decreased most markedly in intensive care units (59% decline), followed by surgical (44%) and medical (32%) wards. Although the ICUs had a steady decline in MRSA burden, the decrease in medical wards was seen only after the launch of the hand sanitizer effort. The use of hand sanitizer increased steadily when averaged for all facilities (from 2 L per 1,000 hospital days to 21 L), but more dramatically (to 26 L) in acute care hospitals.
Because the study was a pragmatic intervention designed to deal with high MRSA rates, observers should be cautious in assuming a causal association between the effort and the MRSA rates, the study authors noted. However, MRSA rates were on the increase at the time of the intervention and other studies have found marked increases in MRSA in other European hospitals during the same time period.
The researchers concluded that an intensive long-term program can result in a sustained reduction of MRSA burden at large institutions with high endemic rates. However, they noted that the studied hospitals’ rates remain high in comparison to others in northern Europe and that anti-MRSA efforts need to be maintained and expanded. The study was published in the March 22 Archives of Internal Medicine.
Program can help opioid-dependent inpatients transition to outpatient treatment
A program to identify at-risk, opioid-dependent inpatients can successfully engage a sizable number of those patients in outpatient addiction treatment, a new study found.
From January 2002 to January 2005, a nurse at Boston Medical Center identified, assessed and enrolled 203 out-of-treatment, opioid-dependent drug users based on their receipt of methadone during hospitalization. Patients transitioned upon discharge to an outpatient interim opioid agonist program that provided 30-day stabilization, followed by 60-day taper. The nurse also provided case management that emphasized HIV risk reduction, health education, medical follow-up and counseling. The study was published online in the March 17 Journal of General Internal Medicine.
Of the 203 patients who initially enrolled during hospitalization, 59% received treatment, 26% didn't receive treatment and 16% weren't able to receive treatment due to medical problems, psychiatric issues or incarceration. Among those who enrolled initially but didn't receive treatment, 46% didn't show at the methadone clinic or left the hospital against medical advice, and 54% didn't show at a long-term opioid treatment program (OTP) clinic for 14 consecutive days or were discharged for behavioral issues.
Thirty-five percent of the 203 patients enrolled in a long-term OTP, while 15% completed methadone taper, 4% entered outpatient or residential substance abuse treatment, and 2% entered an inpatient detoxification facility. Of the 167 patients who became participants at the OTP clinic, 56% obtained discharge prescriptions, 54% attended a primary care appointment, 50% attended two or more group counseling sessions, 17% attended a needle-exchange program, and 16% attended a twelve-step program.
With the provision of interim opioid agonist treatment and a range of treatment intensity options, opioid-dependent inpatients can be linked to appropriate outpatient addiction care and medical care, the authors concluded. The model studied represents a single health care system's experience and thus findings are preliminary, they cautioned. Because there was no comparison group, it wasn't possible to quantify the relative improvement in addiction treatment; still, most participants weren't seeking treatment when they were hospitalized and few would have received treatment had they not enrolled in the study's program, the authors said.
Don’t use Rotarix vaccine, FDA warns
Health care professionals should temporarily suspend the use of Rotarix, one of the vaccines used to prevent rotavirus disease, the FDA recommended last week.
The suspension is being taken as a precaution after DNA from porcine circovirus type 1 (PCV1) was found in Rotarix. PCV1 is not known to cause disease in humans and the FDA reports no evidence of a safety risk. No medical follow-up is recommended for patients who have been vaccinated with Rotarix, according to the FDA safety alert.
However, use of the other licensed rotavirus vaccine, RotaTeq, is currently advised. In children who have received one dose of Rotarix, clinicians can complete the series with RotaTeq for the next two doses, according to the CDC..
High dose of simvastatin poses muscle injury risk
Patients taking high doses of simvastatin (Zocor) face an increased risk of myopathy, according to a new warning from the FDA.
Although muscle injury is a known side effect with all statins, the warning highlights the greater risk of developing muscle injury, including rhabdomyolysis, for patients who take the 80 mg dose of this drug, the FDA said. Rhabdomyolysis is the most serious form of myopathy and can lead to severe kidney damage, kidney failure, and sometimes death.
The FDA’s data on simvastatin were derived from observational studies, adverse event reports, prescription use data, and clinical trials, including the SEARCH (Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine) trial, which evaluated patients taking 80 mg compared to 20 mg of simvastatin.
In addition to being sold as a single-ingredient generic medication and as the brand-name Zocor, simvastatin is sold in combination with ezetimibe as Vytorin and in combination with niacin as Simcor.
Cartoon caption contest.
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.
"We had to clone our interns to meet the latest work hour rules."
This issue's winning cartoon caption was submitted by Ami Shah, ACP Member, a rheumatologist at Johns Hopkins University in Baltimore, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 168 ballots online to choose the winning entry. Thanks to all who voted!
The winning entry captured 37.5% of the votes.
The runners-up were:
"We had a rough year in the Match."
"So, what's alien you?"
"They thought I was discussing a problem with Uranus."
ACP Hospitalist continues its cartoon caption contest next week.
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