In 2005, the IDSA and ATS issued guidelines on the treatment of pneumonia in hospitalized patients, and included a new categorization of healthcare-associated pneumonia (HCAP) for patients with recent interface with medical facilities (guidelines). In this prospective cohort, researchers identified 362 patients with CAP, HAP, or HCAP, and determined rates of guideline-appropriate treatment and mortality. Patients with HCAP were much less likely to receive guideline-concordant antibiotics (27%) than patients with CAP (59%) or HAP (69%), and their mortality was much higher (18%) than patients with CAP (7%) (abstract). As a reminder, HCAP patients include: nursing home or long-term care facility residents, anyone hospitalized (2+ days) in the last 90 days, or anyone undergoing hemodialysis / wound care / chemotherapy / IV antibiotics in the last 30 days. These patients should be treated with 2 anti-pseudomonal drugs and 1 anti-MRSA drug (guidelines)

In this small study of 37 patients with suspected endocarditis, researchers examined the diagnostic accuracy of CT (compared to TEE or surgery), in detecting endocarditis. CT (on per valve evaluation) compared favorably to TEE (PPV 93% and NPV 98%) and surgery (PPV 96% and NPV 97%) in detecting valve abnormalities (vegetations, abscesses, perforations, fistulas, or valve dehiscence) (abstract). The authors conclude CT could be usefulfor endocarditis diagnosis after an initial TEE is negative / inconclusive, or for prosthetic valves when metallic artifacts obscure valve visualization on a TEE. Additional pre-op benefits include better anatomic mapping,  and ruling in (or out) co-existing CAD (instead of angiography).

In this multicenter trial of 500 patients >age 60, patients were randomized to CHF medical titration based on symptoms alone (goal NYHA class <2), or symptoms + BNP (goal of <2 times upper limit of normal). There was no difference in 18 month quality of life, overall survival, or survival free hospitalizations, but the BNP-guided group did have fewer CHF hospitalizations (62% vs 72%) (only found in those <age 75) (abstract). An editorialist advocates using BNP to titrate CHF medications in patients <75 years old (editorialist). Although this was an outpatient study, this data give some credence to the common practice of using BNP measurements to gauge CHF treatment success in the inpatient setting.

In this multi-institutional cross-sectional analysis, researchers measured physician’s use of IT (CPOE, decision support, and automated notes). They found automated notes decreased in-hospital mortality (15% for every 10 point increase in use), CPOE decreased MI death by 9% and CABG death by 55%, and decision support decreased in-hospital complications by 16%. They all reduced cost. Although we cannot prove causality, this is the best evidence to date to turn IT non-believers into believers (abstract)

In this single-institution point-prevalence culture survey, researchers found contamination with Cdiff in 16% on non-isolation rooms, 31% of physician work areas, 10% of nurses work areas, and 21% of portable pieces of equipment. Although this was in the setting of a Cdiff outbreak, it reminds us that Cdiff spores are environmentally hearty, and that handwashing before and after EVERY patient contact is absolutely essential! (abstract)

A new consensus statement has been issued for vancomycin dosing. Highlights include: For patients with normal renal function, dose should be 15-20mg/kg (actual body weight) q8-12 hrs. Trough levels (obtained after the 4th dose) should be >10mg/L for most patients, but should be >15mg/L for MIC’s >1, or for complicated infections (osteo, meningitis, endocarditis, staph pneumonia) (guidelines).

FDA labeling of warfarin includes to consider genetic testing when initiating warfarin, although few patients are offered this testing. Over 30 genes contribute to warfarin dosing effects, but 1/3 of the variance is controlled by polymorphisms in 2 genes: cytochrome P450 (CYP2C9) and vitamin K epoxide reductase (VKORC1). In this cost-effective analysis (abstract), the authors determine that testing afib patients for these 2 genes upon initiation of warfarin  (with genotype-guided dosing), is only cost-effective if their risk of bleeding is high (HEMORR2HAGES score >1) (abstract), depending on the cost of the testing. Currently the cost of such testing is about $400, so should be considered ONLY in patients at high risk for bleeding.

Although commercially-available jarred peanut butter is not implicated, consumers should avoid peanut butter-containing products (cakes, cookies, crackers, candies, cereal, and ice cream) (CDC site); a full list of implicated and recalled products is available on the FDA website (FDA site)

In this large case-control study, rates of sudden cardiac death were twice as high in anti-psychotic users (versus non-users) with a significant dose-response relationship (abstract). For typical anti-psychotics, incidence rate ratios of death (compared to nonusers) were 1.3 (low dose) to 2.4 (high dose). For atypical agents, the ratios of death were 1.6 (low dose) to 2.9 (high dose).  This study reminds us that both typical and atypical anti-psychotics have been associated with an increase the risk of sudden cardiac death. Although causality has not be proven, their use (and dose) should be minimized (if possible) in the inpatient setting.

Usually the decision to stent a coronary vessel is primarily determined by the % stenosis of the vessel. In this RCT of >1000 patients, they were randomized to stenting according to angiography alone, or to angiography in addition to the Fractional Flow Reserve (FFR; ratio of maximal blood flow in a stenotic vessel versus normal maximal blood flow). In the FFR group, the vessel was stented only if the FFR was <0.8. The numbers of stents per patient in the standard group was 2.7, versus 1.8 in the FFR group. The primary endpoint (1-year death, MI, or re-vascularization) occured in 18% of the standard group and only 13% of the FFR group. We should be aware that using FFR in addition to standard angiography will likely be used to guide stenting decisions in the cath lab. (abstract)