Update in Hospital Medicine 2015 Brad Sharpe, MD UCSF Division of - PDF document

4/8/16 Update in Hospital Medicine 2015 Brad Sharpe, MD UCSF Division of Hospital Medicine Midwestern Sports 1

4/8/16 VS. Update in Hospital Medicine Update in Hospital Medicine 2015 • Updated literature • Jan 2015 – Jan 2016 Process: • CME collaborative review of journals ▪ Including ACP J. Club, J. Watch, etc. • Four hospitalists ranked articles ▪ Definitely include, can include, don’t include Update in Hospital Medicine Update in Hospital Medicine Thank you to Michelle Mourad, Will Southern, Amit Pahwa, Mel Anderson 2

4/8/16 Update in Hospital Medicine 2015 Chose articles based on 3 criteria: 1) Change your practice or teaching 2) Modify your practice or teaching 3) Confirm your practice or teaching • Hope to not use the words: Student’s t-test, meta-regression, Mantel-Haenszel • statistical method, etc. Focus on breadth, not depth • Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine 2015 • Major reviews/short takes • Case-based format • Multiple choice questions • Promote retention Update in Hospital Medicine Update in Hospital Medicine 3

4/8/16 Syllabus/Bookkeeping • No conflicts of interest • Final presentation available by email sharpeb@medicine.ucsf.edu Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine 4

4/8/16 Case Presentation You are long-call and your hard-working intern presents the next case. She describes a 63 year-old man with a history of COPD and diabetes who presented with 3 days of fever, cough, and shortness of breath. On presentation, his vitals were temperature 38.9 o C, blood pressure 110/65, heart rate 100s, respiratory rate 28, and oxygen saturation 87% on room air, 96% on 2 liters. Update in Hospital Medicine Case Presentation His exam was notable for diffuse expiratory wheezes and crackles at the right base. His white blood cell count is 18,000 and his CXR shows a clear RLL infiltrate. The team has diagnosed him with community- acquired pneumonia (CAP) and a COPD exacerbation and is admitting him to the stepdown unit. Update in Hospital Medicine 5

4/8/16 Case Presentation The intern states they will treat him with ceftriaxone and azithromycin. The resident then asks, “Hey, I read this New England Journal of Medicine study that showed that maybe we don’t need the atypical coverage for pneumonia. What do you think about this study?” Update in Hospital Medicine How do you respond to the resident about the recent NEJM study on treatment of CAP? A. Regardless of that study, this sounds like a pretty typical pneumonia – it’s probably strep pneumo. Let’s just go with the ceftriaxone. B. I think it’s a good study. We probably don’t need the atypical coverage in this case. C. I think it’s a good study. But I don’t think it is enough to change practice; let’s stick with the ceftriaxone and azithromycin. D. What do you think about that study? Update in Hospital Medicine 6

4/8/16 Treatment of CAP Question: Do patients with CAP admitted to a non-ICU setting need atypical coverage? Design: Cluster-randomized, crossover trial, 7 hospitals in the Netherlands 2283 pts. w/ CAP; mild-mod illness 1) β -lactam (amoxicillin, amox + clavulanate, 3 rd -gen ceph.) 2) β -lactam + macrolide (azithro, clarithro, erythro) 3) Fluoroquinolone (levo or moxi) ▪ Antibiotics could be adjusted Postma DF, et al. NEJM . 2015;372:14. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Results ▪ Nearly 35% got antibiotics before admission ▪ Only 2% had atypicals (Legionella, Mycoplasma) ▪ Deviation in ~ 25% of patients 90-day Length of Intention-to-treat Mortality Stay (d) β -lactam β -lactam + macrolide Fluoroquinolone Update in Hospital Medicine 7

4/8/16 Results ▪ Nearly 35% got antibiotics before admission ▪ Only 2% had atypicals (Legionella, Mycoplasma) ▪ Deviation in ~ 25% of patients 90-day Length of Intention-to-treat Mortality Stay (d) β -lactam 9.0% β -lactam + macrolide 11.1% Fluoroquinolone 8.8% Update in Hospital Medicine Results ▪ Nearly 35% got antibiotics before admission ▪ Only 2% had atypicals (Legionella, Mycoplasma) ▪ Deviation in ~ 25% of patients 90-day Length of Intention-to-treat Mortality Stay (d) β -lactam 9.0% 6 β -lactam + macrolide 11.1% 6 Fluoroquinolone 8.8% 6 ▪ β -lactam non-inferior to both ▪ No difference in adverse events Update in Hospital Medicine 8

4/8/16 Treatment of CAP Question: Do pts. admitted with CAP need atypical coverage? Design: Cluster-randomized; 2283 pts.; β -lactam v. β -lactam + macrolide v. fluoroquinolone Conclusion: β -lactam monotherapy non-inferior to regimens w/ atypical coverage; no difference in side effects Comment: Well-done study, intention-to-treat Generalizable? European study, pre-abx, antibiotic choices, long LOS, etc. Not quite enough to change practice; β -lactam + macro/doxy or fluoroquinolone Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Postma DF, et al. NEJM . 2015;372:14. How do you respond to the resident about the recent NEJM study on treatment of CAP? A. I think regardless of the study, this sounds like a pretty typical pneumonia – it’s probably strep pneumo so let’s just go with the ceftriaxone. B. I think it’s a good study and I think we probably don’t need the atypical coverage in this case. C. I think it’s a good study but I don’t think it is enough to change practice; let’s stick with the ceftriaxone and azithromycin. D. What do you think about that study? Update in Hospital Medicine 9

4/8/16 How do you respond to the resident about the recent NEJM study on treatment of CAP? A. I think regardless of the study, this sounds like a pretty typical pneumonia – it’s probably strep pneumo so let’s just go with the ceftriaxone. B. I think it’s a good study and I think we probably don’t need the atypical coverage in this case. C. I think it’s a good study but I don’t think it is enough to change practice; let’s stick with the ceftriaxone and azithromycin. D. What do you think about that study? Update in Hospital Medicine Case Presentation The resident nods but you get a sense she is skeptical of your analysis. So you decide to pull out this article to bolster your argument: Update in Hospital Medicine 10

4/8/16 Short Take: Treatment of CAP In an RCT in Switzerland, 580 patients with mild- moderate CAP admitted to the hospital received β - lactam monotherapy or β -lactam + macrolide. β -lactam monotherapy was not non-inferior (i.e. was inferior) in failure to reach clinical stability at day 7 (41.3% vs. 33.4%, p=0.07). β -lactam monotherapy also led to higher rates of 30- day readmission (7.9% vs. 3.1%, p=0.01). Garin N, et al. JAMA Intern Med. 2015;174:1894. Update in Hospital Medicine Case Presentation The resident is, well, still not impressed. But, the patient receives ceftriaxone and azithromycin. Over lunch you are discussing the case with a colleague and she asks, “Are you giving the guy steroids for his pneumonia?” “Steroids, for pneumonia?” you ask. She shows you this article. Update in Hospital Medicine 11

4/8/16 Case Presentation Update in Hospital Medicine What is the role for systemic corticosteroids in the management of CAP? A. There is no role for steroids in CAP unless they are also having a COPD exacerbation. B. Steroids may improve clinical outcomes in CAP but there is no mortality benefit. C. Steroids reduce mortality in CAP . D. Steroids? In pneumonia? Sure, if you want to kill the guy. Umm, it’s uh, like an infection. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine 12

4/8/16 Steroids in CAP Question: In community-acquired pneumonia (CAP), what is the effect of corticosteroids? Design: Systematic review & meta-analysis; Total of 13 studies, 2005 patients; All RCT with steroids vs. placebo ▪ Variable drugs, doses, routes, durations ▪ Both moderate & severe pneumonia Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. Update in Hospital Medicine Update in Hospital Medicine Results Steroids vs Placebo Outcome Hospital Mortality Ventilation Time to Stability Length of Stay Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. 13

4/8/16 Results Steroids vs Placebo Outcome Hospital Mortality RR 0.67 (0.45-1.01); p=0.06 Ventilation Time to Stability Length of Stay Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. Results Steroids vs Placebo Outcome Hospital Mortality RR 0.67 (0.45-1.01); p=0.06 Ventilation RR 0.45 (0.26-0.79); p<0.05 Time to Stability Length of Stay Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. 14

4/8/16 Results Steroids vs Placebo Outcome Hospital Mortality RR 0.67 (0.45-1.01); p=0.06 Ventilation RR 0.45 (0.26-0.79); p<0.05 Time to Stability -1.22 days (-2.0 to -0.35); p<0.05 Length of Stay Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. Results Steroids vs Placebo Outcome Hospital Mortality RR 0.67 (0.45-1.01); p=0.06 Ventilation RR 0.45 (0.26-0.79); p<0.05 Time to Stability -1.22 days (-2.0 to -0.35); p<0.05 Length of Stay -1.0 days (-1.79 to -0.21); p<0.05 ▪ Biggest benefits in sicker patients ▪ Slight increase in hyperglycemia (3.5%) Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. 15