Hospital Medicine Update: High-Impact Literature from March 2018 to April 2019
To assist busy hospital medicine clinicians, we summarized 10 impactful articles from last year. The authors reviewed articles published between March 2018-April 2019 for the Hospital Medicine Updates at the Society of Hospital Medicine and the Society of General Internal Medicine Annual Meetings. The authors voted to select 10 of 30 presented articles based on quality and clinical impact for this summary. The key findings include: (1) Vancomycin or fidaxomicin are the first-line treatment for initial Clostridioides difficile infection; (2) Unnecessary supplemental oxygen is linked to increased mortality; aim for a target oxygen saturation of 90%-94% in most hospitalized patients; (3) Stigmatizing language in medical records impacts physician trainees’ attitudes and pain management practices; (4) Consider ablation for atrial fibrillation in patients with heart failure; (5) Patients with opioid use disorder should be offered buprenorphine or methadone therapy; (6) Apixaban is safe and may be preferable over warfarin in patients with atrial fibrillation and end-stage kidney disease; (7) It is probably safe to discontinue antimethicillin-resistant Staphylococcus aureus (MRSA) coverage in patients with hospital-acquired pneumonia who are improving and have negative cultures; (8) Selected patients with left-sided endocarditis (excluding MRSA) may switch from intravenous (IV) to oral antibiotics if they are clinically stable after 10 days; (9) Oral antibiotics may be equivalent to IV antibiotics in patients with joint and soft tissue infections; (10) A history–electrocardiogram–age–risk factors–troponin (HEART) score ≥4 is a reliable threshold for determining the patients who are at risk for short-term major adverse cardiac events and may warrant further evaluation.
© 2019 Society of Hospital Medicine
Partial Oral versus Intravenous Antibiotic Treatment for Endocarditis (POET). Iversen K et al. New Engl J Med. 2019;380(5):415-424.11
Background. Patients with left-sided infective endocarditis are typically treated with up to six weeks of intravenous (IV) antibiotics. The investigators studied the effectiveness and safety of switching to oral antibiotics after at least 10 days of IV therapy.
Findings. This randomized, multicenter, noninferiority trial at cardiac centers across Denmark included 400 adults with left-sided endocarditis who were clinically stable after at least 10 days of IV antibiotics. Half of the patients were randomized to continue IV therapy, whereas the other half was switched to oral antibiotics to complete the treatment course. Six months after therapy, no significant difference was observed between the two groups in terms of the primary composite outcomes, including all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen (IV-treated group: 12.1%; orally treated group: 9.0% [between-group difference: 3.1%; P = .40]).
Caveats. A total of 20% of the screened population (1,954 adults) was randomized, and about 1% (5/400) of patients used injection drugs. None of the patients had MRSA. Patients in the oral group were assessed two to three times per week as outpatients, which may not be feasible in most settings.
Implications. Switching to oral antibiotics after at least 10 days of IV therapy appears to be safe and effective in selected patients with left-sided endocarditis. However, this study largely excluded patients with injection drug use and/or MRSA infections.
Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA). Li HK, et al. New Engl J Med. 2019;380(5):425-436.12
Background. Most complex orthopedic infections are treated with several weeks of IV antibiotics. This study sought to determine whether oral antibiotics are noninferior to IV antibiotics for bone and joint infections.
Findings. This randomized, multicenter, noninferiority, open-label trial of 1,054 adults with bone and joint infections in the United Kingdom included patients with prosthetic joints, other indwelling joint hardware, and native joint infections. Within seven days of antibiotic medication or within seven days of surgery (if performed), the patients received either IV or oral antibiotics for six weeks with a primary endpoint of treatment failure one year after the study randomization. The choice and duration of antibiotic treatment were determined by the involved infectious disease physician. A majority (77%) of patients received greater than six weeks of therapy. Treatment failure was defined by clinical, microbiologic, or histologic criteria. Most enrolled patients were infected with Staphylococcus aureus, with 10% having methicillin-resistant S. aureus. Treatment failure was more frequent in the IV group than the oral group (14.6% vs 13.2%), and these findings were consistent across all subgroups. More patients discontinued treatment in the IV group than the oral group.
Cautions. This study included a heterogenous population of patients with bone and joint infections, with or without hardware, and with different species of bacteria. Patients with bacteremia, endocarditis, or another indication for IV therapy were excluded. Limited injection drug use history was available for the enrolled patients. Most patients had lower limb infections. Thus, these findings are less applicable to vertebral osteomyelitis. Additionally, the study offered no comparison of specific antibiotics.
Implications. With appropriate oversight from infectious disease specialists, targeted oral therapy may be appropriate for the treatment of osteomyelitis. This shift in practice likely requires more study before broad implementation.
