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In the News
for the Week of 3-9-11
Highlights
Acute heart failure outcomes don't differ by furosemide dose level, interval of administration
Outcomes for patients with acute decompensated heart failure don't differ when furosemide is delivered via continuous infusion versus bolus, or at a high dose versus a low dose, a new study found. More...
Central line infections in ICUs fell 58% between 2001 and 2009
Central line-associated bloodstream infections in ICUs dropped 58% between 2001 and 2009, the Centers for Disease Control and Prevention reported last week. More...
Perioperative care
Clopidogrel may improve outcomes after CABG in patients with MI
Clopidogrel may improve outcomes after coronary artery bypass grafting (CABG) for myocardial infarction (MI), a new study reports. More...
Infectious disease
Skin infection guideline improved stewardship
Implementation of a guideline on treatment of cellulitis and cutaneous abscesses significantly improved one hospital's antimicrobial stewardship, a new study found. More...
FDA news
Unapproved prescription cough, cold, allergy meds pulled
The FDA ordered the market removal of a large number of prescription oral cough, cold, and allergy products last week. More...
Internal Medicine 2011
ACP Job Placement Center calls for job seekers' profiles
Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2011, to be held April 7-9 in San Diego. More...
Cartoon Caption Contest
Put words in our mouth
ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...
Physician editor: A. Scott Keller, FACP
Highlights
.
Acute heart failure outcomes don't differ by furosemide dose level, interval of administration
Outcomes for patients with acute decompensated heart failure don't differ when furosemide is delivered via continuous infusion versus bolus, or at a high dose versus a low dose, a new study found.
In a prospective, double-blind trial, researchers randomized 308 patients with acute decompensated heart failure to intravenous furosemide given every 12 hours (bolus) or continuously, and at a dose equal to the patient's previous oral dose (low dose) or 2.5 times the previous dose (high dose). Treatment was continued for up to 72 hours. At 48 hours, the treating physician could, based on clinical response, maintain the current strategy, increase the dose by 50%, or stop intravenous treatment and use open-label oral diuretics instead. The primary end points were change in serum creatinine level from baseline to 72 hours and the patients' global assessment of symptoms. Results were published in the March 3 New England Journal of Medicine.
There was no significant difference in patients' global assessment of symptoms whether they had received bolus or continuous infusion (mean area under the curve [AUC], 4,236 ± 1,440 and 4,373 ± 1,404, respectively; P=0.47) or in the mean change in creatinine level (0.05 ± 0.3 mg/dL and 0.07 ± 0.3 mg/dL, respectively; P=0.45). There was also no significant difference between the
high- and low-dose strategy, though there was a trend toward the high dose improving symptoms (mean AUC, 4,430 ± 1,401 vs. 4,171 ± 1,436; P=0.06). High and low doses didn't yield a significant difference in mean creatinine level, either (0.08 ± 0.3 mg/dL vs. 0.04 ± 0.3 mg/dL, respectively; P=0.21). The high-dose approach was associated with transient worsening of renal function, but greater diuresis, greater relief of dyspnea and fewer serious adverse events.
While prior, smaller studies have suggested continuous infusion leads to less renal dysfunction and greater diuresis than bolus, the current study found no difference. This may be because bolus patients used continuous placebo infusion, which increased the time the patients were supine—a position that has been shown to increase diuresis, the authors noted. Separately, they cautioned that the patients in this study had a history of chronic heart failure and required moderate to high doses of loop diuretics as outpatients; the results may not apply to patients with more modest diuretic requirements or newly diagnosed heart failure. The dose and interval findings should change practice, according to an editorialist. "Since a high-dose regimen may relieve dyspnea more quickly without adverse effects on renal function, that regimen is preferable," he wrote. "Administration of boluses may be more convenient than continuous infusion and equally effective," he added.
.
Central line infections in ICUs fell 58% between 2001 and 2009
Central line-associated bloodstream infections (CLABSIs) in ICUs dropped 58% between 2001 and 2009, the Centers for Disease Control and Prevention reported last week.
CDC researchers multiplied central line utilization and CLABSI rates by estimates of the total number of patient-days in ICUs, inpatient wards and outpatient hemodialysis facilities. They used the Healthcare Cost and Utilization Project's National Inpatient Sample and the Hospital Cost Report Information System to identify total inpatient days; CLABSI and central line use rates came from the National Nosocomial Infections Surveillance Systems for 2001 estimates (ICUs only) and from the National Healthcare Safety Network (NHSN) for 2009 estimates (ICUs and inpatient wards). Total number of outpatient hemodialysis patient-days in 2008 came from the U.S. Renal Data System; outpatient hemodialysis central line utilization data came from the Fistula First Breakthrough Initiative; and hemodialysis CLABSI rates were estimated from the NHSN. Results were published online March 1 by the CDC's Morbidity and Mortality Weekly Report.
ICU CLABSIs fell to about 18,000 cases in 2009 from about 43,000 cases in 2001. Reductions in infections caused by Staphylococcus aureus were greatest (73% reduction; rate ratio [RR], 0.27; 95% CI, 0.238 to 0.294), followed by those caused by Enterococcus species (55% reduction; RR, 0.45; 95% CI, 0.408 to 0.491), Candida species (46% reduction; RR, 0.54; 95% CI, 0.487 to 0.606) and gram-negative pathogens (37% reduction; RR, 0.63; 95% CI, 0.568 to 0.692). Overall, the decline in infections saved up to 6,000 lives and $414 million in potential excess health care costs in ICUs in 2009 alone, and saved an estimated 27,000 lives and $1.8 billion in excess health care costs in ICUs since 2001. Still, a substantial number of CLABSIs occurred in inpatient wards and outpatient hemodialysis centers. While data for 2001 weren't available, there were an estimated 23,000 CLABSIs in inpatient wards in 2009 and 37,000 in outpatient hemodialysis centers in 2008.
Collaboration among health care facilities, professional societies and state and federal agencies to implement proven best practices for central line insertion has likely helped reduce CLABSIs in ICUs, the report concluded. Such efforts may have limited impact outside the ICU, where central lines are less frequently inserted, so extra prevention strategies should be developed, it said. "Implementation of CDC recommendations to maintain central lines, remove them promptly when they are no longer needed, and interrupt transmission of resistant bacteria will reduce CLABSIs further," the report said. Study limitations include that estimates were calculated rather than measured directly, and that differences between facilities reporting and not reporting data to CDC may have affected the accuracy of estimates.
Perioperative care
.
Clopidogrel may improve outcomes after CABG in patients with MI
Clopidogrel may improve outcomes after coronary artery bypass grafting (CABG) for myocardial infarction (MI), a new study reports.
To evaluate the effect of clopidogrel on death and recurrent MI after CABG, Danish researchers examined data on patients admitted to the hospital with a first MI between 2002 and 2006 who underwent CABG within 180 days. They determined which patients received clopidogrel after discharge by looking at filled prescriptions. The main outcome measures were risk for death, recurrent MI or both. The study results appear in the March 8 Journal of the American College of Cardiology.
Study patients were followed for a mean of 466 ± 144 days. A total of 3,545 patients were included, 957 (27.0%) of whom received clopidogrel after CABG. Thirty-nine (4.1%) of those who received clopidogrel died or had a recurrent MI compared with 203 (7.8%) of those who did not receive clopidogrel (log-rank P=0.0003; hazard ratio, 0.59; 95% CI, 0.42 to 0.85). In a subgroup analysis of 945 patients matched by propensity score, 38 (4.0%) of those treated with clopidogrel died or had recurrent MI compared with 57 (6.0%) of those not treated with clopidogrel (log-rank P=0.05; hazard ratio, 0.67; 95% CI, 0.44 to 1.00). Rates of bleeding events after hospital discharge did not differ between groups.
The study was limited by its observational design, which did not allow the authors to definitively establish a causal relationship between clopidogrel and the primary outcomes. The authors also could not rule out selection bias. However, they concluded that clopidogrel treatment helped improve outcomes in patients with MI after CABG, but that the percentage of eligible patients who received clopidogrel treatment was low. They said that a randomized, controlled trial is warranted to clarify the relationship between postoperative clopidogrel treatment and outcomes, and that more attention should be paid to prescribing clopidogrel at discharge in this group of patients.
Infectious disease
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Skin infection guideline improved stewardship
Implementation of a guideline on treatment of cellulitis and cutaneous abscesses significantly improved one hospital's antimicrobial stewardship, a new study found.
Having observed that antibiotic therapy for cellulitis and cutaneous abscesses was often overly broad and of excessive duration, researchers at Denver Health Medical Center developed and implemented a guideline in 2008. The guideline called for empirical use of vancomycin, discouraged use of antimicrobial agents with broad aerobic gram-negative or anaerobic activity, and called for therapy limited to seven days. The guideline also discouraged using serum erythrocyte sedimentation rate (ESR), superficial wound cultures, and CT or MRI scanning for diagnosis.
A retrospective study compared management of cellulitis and cutaneous abscesses before (169 patients) and after (175 patients) the guideline was developed and implemented. According to results published online by Archives of Internal Medicine on Feb. 28, the intervention was successful in reducing the percentage of patients receiving drugs with broad aerobic gram-negative activity (66% before vs. 36% after; P<0.001), antipseudomonal activity (28% vs. 18%; P=0.02) and broad anaerobic activity (76% vs. 49%; P<0.001). The median duration of therapy also decreased from 13 days to 10 days. Patients who received shorter durations of therapy, and the post-intervention group as a whole, saw no increase in clinical failure, the study authors noted.
The intervention also reduced the use of some diagnostic resources. Use of microbiological cultures dropped from 80% to 66% (P=0.003), and requests for inpatient consultation decreased from 46% to 30% (P=0.004), the latter likely due to clinicians becoming more confident about the appropriate course of treatment, the study authors speculated. Use of blood cultures and MRI also dropped, but the effort to decrease serum ESR use was not successful.
Based on the results of the study, this intervention should be considered by other hospitals and antibiotic stewardship programs, the study authors concluded. The process requires rigorous evaluation of current practices, assembly of peer champions, and multifaceted implementation, including audit and feedback, the authors said. Their implementation program included widespread dissemination by e-mail, additional education efforts and the development of an electronic order set.
An accompanying commentary cheered the success of the guideline, but concluded that the study also highlights how much still needs to be done, given that even after the intervention large percentages of patients were still receiving inappropriately lengthy and broad therapy. As the commentary author wrote, "it is inexcusable to prescribe prolonged courses of therapy with antibiotics that have broad [gram-negative bacilli] activity when treating [skin and soft tissue infections] caused by streptococci and S. aureus."
FDA news
.
Unapproved prescription cough, cold, allergy meds pulled
The FDA ordered the market removal of a large number of prescription oral cough, cold, and allergy products last week.
The drugs had not been approved by the agency, but because the drugs' labels do not disclose that they lack FDA approval, clinicians may have been unaware of the unapproved status of the drugs and continued to prescribe them, an FDA news release said. Over the past century, the laws outlining the requirements for drug approval have changed. In part as a result of these changes, many of the products targeted by this FDA action have been marketed without being approved under the current legal requirements.
There are numerous potential concerns about these products, FDA officials said. Some may contain risky combinations of ingredients, while others—marketed as timed-release—may release active ingredients too slowly, too quickly, or inconsistently. The agency has also received reports that some products have names that look or sound similar to other products. The FDA therefore concluded that the products pose unnecessary risk to consumers, especially given that approved prescription drugs and over-the-counter drugs that meet FDA standards are available to treat the same symptoms.
Most of the companies that distribute these drugs have been ordered to stop production within 90 days and distribution within 180 days, but some companies may be required to stop immediately. A full list of the affected products is available online.
Internal Medicine 2011
.
ACP Job Placement Center calls for job seekers' profiles
Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2011, to be held April 7-9 in San Diego.
The center, located in the San Diego Convention Center's Exhibit Hall, Booth #1601, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.
Profiles will be included in one of two booklets distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting that meets your criteria. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the center. Profiles can be submitted online.
Cartoon Caption Contest
.
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 finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.
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