What’s ahead in gram negative infections?

An article from Expert Review of Anti-Infective Therapy examines the emerging threats of resistant gram negative organisms and what we have now, or in the pipeline, to deal with them. In general there are few gram negative agents in late stages of development.

At present, Tygecycline is a consideration for Acinetobacter baumannii infections although its role is uncertain. A. baumannii frequently causes pulmonary infections. In that connection the recently reported failure of Tygecycline in the phase III HAP/VAP trial is concerning.

Is it woo or is it real?

Maybe a little of both?

This demonstration took place on I've Got a Secret, a popular CBS game show from the early 60’s

Neurologists, psychiatrists, skeptics, what’s going on?

(Don’t try this at home).

Discharge planning after glycemic control in hospitalized patients

So you’ve done a good job controlling your critically ill patient’s blood sugar with an insulin drip. The patient has recovered and discharge is approaching. Now what? This CME approved Medscape article provides some tips for the transition to out patient care.

A while back, after an exchange with Dr. Daniel Carlat, author of the Carlat Psychiatry Blog (really more of a pharma-critical site than a psychiatry blog) I vowed to asses all Medscape CME offerings I post for bias, imbalance and non-evidence based content. This has gotten to be a competition between collections of anecdotes (which, mind you, do not equal evidence).

The activity in question is based entirely on an article from the Medscape Journal of Medicine. Editorial assistance for the article was provided by the makers of Lantus. (Does that mean it is one of those dreaded ghost written articles?). The author received no financial support from industry. The CME activity itself is non-industry supported.

Ghost written or not, the article can easily be critically appraised by examination of primary sources of evidence. The only thing I found that was non-evidence based and unbalanced was the discussion of glycemic control via insulin drips in the initial phase of critical illness and acute coronary syndrome. Specifically, the article selectively cites evidence in favor of tight glycemic targets while tending to ignore negative studies and the prevailing controversy surrounding in patient glucose control.

The principal focus of the article is on the transitions from insulin drip to sub q insulin to discharge. Those sections contain helpful tables and text on basal bolus regimens. Although they mention the pharmacokinetic advantages of the newer insulins none are mentioned by brand name and no clear recommendation for one over others is made.

My final take? The only unbalanced portion of this presentation was the promotion of plain old regular insulin and had nothing to do with the company which was in a position to influence content.

Injectable second generation antipsychotics and benzodiazepines in combination: safety considerations

For years we’ve combined or alternated injectable benzodiazepines (e.g. Ativan) with injectable first generation antipsychotics (e.g. Haldol) to manage delirium and agitation in hospitalized patients based on the rationale that the pharmacologic properties of one may complement and help minimize adverse effects of the other. The use of second generation antipsychotics in such combinations has become somewhat popular as these agents became available in parenteral form. However, such use has brought to light unanticipated cardiovascular and respiratory safety concerns particularly with Olanzapine (Zyprexa). This has led at least one institution to implement restrictions which are explained, along with a brief review of pertinent literature, in an article in the American Journal of Health-System Pharmacy. The full text is provided via Medscape.

Exciting developments in the medical blogosphere

Just as I endeavor to increase the readability and usability of Notes from Dr. RW as a hospitalist (primarily clinical) blog two other developments are noteworthy. First, Docnotes (formerly known as Family Medicine Notes) plans to rev things up after a period of dormancy. Jacob Reider, the blog author, put it this way in a recent post:

The past two years - this blog has been stale - due to my professional role mirroring my personal interests in a way that makes my thoughts potentially company secrets that can't be shared.

I'm working on ways to change that so that this blog once again becomes the valuable asset that it once was. Stay tuned.

Those not long in the blogging world will under appreciate this development. Jacob (who also maintains the aggregator Medlogs) is a medical blogging pioneer. Family Medicine Notes started in 1999 and as far as I know is the oldest medical blog extant. It, along with Medrants, Medpundit and RangleMD got me interested in blogging. For its first several years it was a place for lively discussions of clinical medicine, healthcare informatics and the state of blogging in general. Then, as a result of competing interests and responsibilities, things began to slow down. For the past couple of years it has functioned mainly as a listing of links, largely on informatics topics of narrow interest, with just enough content to avoid Grunt Doc’s obituary listing. I didn’t always agree with Jacob but I enjoyed reading his clinical discussions and valued his expertise on blogging.

Then, just today, I discovered Hospital medicine Quick Hits written by academic hospitalist Danielle Schuerer. This is another SHM sponsored blog and it’s purely clinical---a nice complement to Bob Wachter’s blog which emphasizes the administrative side. Judging from the content posted so far it looks to be another valuable clinical resource for hospital medicine. I’ll be lurking and linking often.

I’ve gone green

---with a new blog design that readers may find a little easier on the eyes. Better yet, the search engine up top actually works now. Long overdue category archive and blog roll updates, along with other tweaks, are coming soon.

Liberation from mechanical ventilation

In the resources linked here the term “weaning” is often misused in reference to the process of liberating patients from ventilators. “Weaning” harks back to the days when we used sequential reductions of SIMV or pressure support levels to get patients off ventilators, methods which became obsolete more than a decade ago. Rather than weaning most patients need daily assessment for readiness for extubation. The patients who need weaning are the exceptions. If your patient truly needs weaning you might want to get help from a pulmonologist.

With that clarification out of the way it’s time for me to update an old post which summarized recommendations on this topic. That post presented an evidence based method for daily extubation assessment of mechanically ventilated patients, focusing on the spontaneous breathing trial (SBT). Although I stand by the premise of that post it needs updating in light of this study which looked at integrating the daily SBT with a daily spontaneous awakening trial (SAT) as a protocol. Given that daily SATs (sedation interruptions) and SBTs are commonplace (or should be) in mechanically ventilated patients what’s so new and different about this? I don’t know for sure, but when those two procedures were organized in the form of an explicit protocol they out performed usual care in several metrics including mortality (NNT=7!). So what was usual care? Surprisingly it looked pretty evidence based---it employed the daily spontaneous breathing trial. But, apparently, in the usual care group, given that the SATs were not coordinated with the SBTs as part of an explicit protocol patients tended to be over sedated at the time of their SBT. So more patients flunked their SBT or were judged too sleepy for extubation and thus experienced more days of mechanical ventilation.

In a subsequent review the authors explained their protocol and elaborated on issues surrounding it. For those without full text access here is a graphic of the protocol.

The rift between ER docs and hospitalists

---may have adverse consequences for patient care.

A survey published in the Annals of Emergency Medicine documented numerous handoff errors between ER physicians and hospitalists resulting in near misses and, in some cases, patient harm. Why?

…analysis of responses identified numerous contributors to error: inaccurate or incomplete information, particularly of vital signs; cultural and professional conflicts; crowding; high workload; difficulty in accessing key information such as vital signs, pending data, ED notes, ED orders, and identity of responsible physician; nonlinear patient flow; “boarding” in the ED; and ambiguous responsibility for sign-out or follow-up.

Today’s Hospitalist interviewed one of the study authors:

There’s definitely a lot of ambiguity about who’s responsible for patients who are already signed out to the admitting team or who go to dialysis before going to the floor, or who are reassigned after sign-out to a new team.Most hospitalists say that if the patient is in the ED, the ED doctor is responsible. But the reality is that if the patient is signed out, the ED doctor is mentally finished with that patient and moves on. If his shift ends before the patient goes up to the floor, it’s even worse.Often, all the next ED doctor is told is, “This is Ms. X, who’s been admitted with pneumonia and could disappear in the next 10 minutes.” With most patients that‘s OK, but not all, like acute
asthmatics or diabetics who need hourly monitoring of their insulin drips.

Anyone who’s worked long in this environment knows what’s going on. There tends to be a cultural divide between emergency medicine and hospital medicine. Expectations are mismatched and workflows are misunderstood. There’s no easy fix to the problem but communication is key. Hospitalist groups should meet with their emergency medicine colleagues regularly to discuss cases, offer feedback and improve professional relationships.

Vandy Med students get a lecture on alternative medicine

I have no information about the lecture content but from the picture it was more promotional than science based, I’d wager.

Increased hospital admissions with diagnosis of PE

Not surprising given the increased use of CT, which may be picking up insignificant filling defects in many patients. Graphic here.

CA-MRSA: From epidemic to endemic

With the flu season here it’s a good time to review CA-MRSA, particularly CA-MRSA pneumonia. Emergency Medicine News has a blurb on CA-MRSA pneumonia which references this review in Emergency Medicine Clinics of North America.

Here are a few points of interest from both articles:

CA-MRSA does not represent the old MRSA (HA-MRSA) having escaped to the community. It has distinct microbiologic, clinical and epidemiologic characteristics.

Risk factors for CA-MRSA pneumonia are colonization, prior infection including skin and soft tissue, exposure and recent influenza or influenza like illness (respiratory epithelium damage from antecedent viral infection facilitates bacterial attachment). CA-MRSA should be considered in any case of severe pneumonia.

The PVL toxin imparts unique pathogenicity.

In the initial antibiotic selection for pneumonia, the IDSA/ATS guidelines say that if CA-MRSA is suspected add vancomycin or linezolid. The Emergency Medicine Clinics article, however, suggests that linezolid is preferred if CA-MRSA pneumonia is suspected. It also points out that both linezolid and clindamycin decrease toxin production, and suggests that if vancomycin is used, clindamycin should be added for life threatening infections.

The Clinics article contains a wealth of information on infection control including the limited indications and regimens for decolonization.

Long time, no post

Just too dang tired to blog last week. Things should ramp up soon.

Intravascular catheter related infections

An article in Expert Review of Anti-Infective Therapy summarizes the latest evidence and recommendations.

Allergic to Wi-Fi?

Some are advocating for Wi-Fi free zones.

H/T to StL Media.net.

Coming soon---ceftobiprole

Via The Annals of Pharmacotherapy:

Ceftobiprole medocaril is an extended-spectrum cephalosporin with activity against methicillin-resistant Staphylococcus spp., vancomycin-resistant Staphylococcus aureus, penicillin-resistant Streptococcus pneumoniae, vancomycin-resistant Enterococcus faecalis, Enterobacteriaceae, and Pseudomonas aeruginosa.

The major hole in this 5th generation cephalosporin? Those pesky ESBLs.

Note: Many VREs are Enterococcus faecium. Ceftobiprole is apparently not active against E. faecium.

Bicarb no better than saline in preventing contrast nephropathy

---in this study. Via JAMA.

Henny Youngman doctor jokes

Here are a few of my favorites:

A doctor gave a man six months to live. The man couldn't pay his bill, so he gave him another six months.

The Doctor called Mrs. Cohen saying, "Mrs. Cohen, your check came back." Mrs. Cohen answered, "So did my arthritis!"

The Doctor says, "You'll live to be 60!" "I AM 60!" "See, what did I tell you?"

The patient says, "Doctor, it hurts when I do this." "Then don't do that!"

"Doctor, my leg hurts. What can I do?" The doctor says, "Limp!"

"Doctor, I have a ringing in my ears." "Don't answer!"

Hospitalist turnover

It’s widely said that a rolling stone gathers no moss. Try telling that to a hospitalist.

Putting evidence into practice: the Surviving Sepsis guidelines

Experts discuss the ins and outs in Today’s Hospitalist.

Disruptive behavior policies---they’re not just about doctors anymore

Today’s Hospitalist interviewed Alan H. Rosenstein, MD, MBA, a long time hospital based physician who has authored several papers on the subject. He notes:

“It’s not physician-bashing,” says Alan H. Rosenstein, MD, MBA, the lead author of the August 2008 study. “And it’s not just physicians who are doing this.”

Traditional discussions on the issue in past years have focused on doctors, but Joint Commission standards set to go into effect in January will now apply to all personnel in the hospital environment, where a zero tolerance policy is recommended.

Regarding hospitalists:

Where do hospitalists fit into this picture? According to Dr. Rosenstein, who began his career as a hospital-based physician before the term “hospitalist” existed, hospitalists tend to be more on the receiving end of bad behavior than on its delivery.