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Mid-Atlantic Hospital Medicine Symposium Delivers Practice Pearls for Hospitalists


 

What do Clostridium difficile, Staphylococcus aureus, and acute pulmonary embolism have in common? They were all topics of discussion at the 2015 Mid-Atlantic Hospital Medicine Symposium, held at the Icahn School of Medicine at Mount Sinai in New York City.

Vikas Saini, MD, FACC, president of the Lown Institute in Brookline, Mass., and associate physician at Brigham and Women’s Hospital in Boston, gave the keynote address on high-value care.

“We’re asking you to do hard things: to be kind to complete strangers, to feel their pain, to be compassionate when you’re on the run,” Dr. Saini said as he urged his fellow physicians to be more personable with patients. “Pull up a chair and sit down. It takes you 30 seconds, but for the patient, it feels like an eternity.” Dr. Saini, a guest lecturer at the symposium, also stressed the importance of being collaborative and encouraged clinicians to join their colleagues in implementing RightCare Rounds.

Following the keynote address, Louis DePalo, MD, an associate professor of pulmonary, critical care, and sleep at Icahn School of Medicine, gave a 30-minute presentation on the management of acute pulmonary embolism (PE).

Dr. DePalo said that in his early days of practicing medicine, PE patients were usually hospitalized without debate. Today, thanks to indices such as the Pulmonary Embolism Severity Index, there are algorithms to determine the severity of PE in patients, allowing doctors to determine whether patients should be discharged or hospitalized. Still, Dr. DePalo added, “Discussions about sending a patient home are complicated.”

If a patient has severe PE, Dr. DePalo advised doctors to analyze studies such as the Pulmonary Embolism Thrombolysis (PEITHO) trial and the Moderate Pulmonary Embolism Treated with Thrombolysis (MOPPETT) trial to determine when to use advanced treatments. “One study may not be sufficient for administering advanced therapies,” Dr. DePalo said. “One study doesn’t make us feel good, so get a lot of data.”

After Dr. DePalo’s presentation, physicians gave presentations on common healthcare-associated infections. Gopi Patel, MD, an assistant professor of infectious diseases at Icahn School of Medicine, discussed Clostridium difficile infection (CDI). “CDI is the most common [healthcare-associated infection] in the United States,” Dr. Patel said as she urged physicians to “be a role model” by practicing good hand hygiene.

Using the updated practice guidelines from the Infectious Diseases Society of America, Tim Sullivan, MD, an assistant professor of infectious diseases at Icahn School of Medicine, discussed skin and soft tissue infections, particularly methicillin-resistant Staphylococcus aureus (MRSA). The guidelines “make a very important distinction between purulent and nonpurulent infections,” Dr. Sullivan said. “The majority of nonpurulent infections are caused by strep, [and] treating for strep seems to be sufficient to cure the infection … Adding extra coverage for MRSA is either not helpful or may actually be harmful to patients.”

Purulent infections, which require drainage, “are mostly caused by Staph aureus, including MRSA,” Dr. Sullivan said. “You don’t always have to give antibiotics, but they are recommended when the patient is sick.”

Dr. Sullivan said although “it can be sort of confusing trying to choose the right antibiotics for your patient … almost everyone should just receive vancomycin.” The drug is well-studied, inexpensive at $2.80 per dose for a five-day treatment, and well-tolerated by patients, he added. Yet vancomycin should not be administered to everyone as some patients experience devastating adverse reactions, and vancomycin could potentially cause irreversible hearing loss, he said.

Dr. Sullivan mentioned three new antibiotic treatments for MRSA: telavancin, which the U.S. Food and Drug Administration approved in 2009, costs 75 times more than vancomycin; dalbavancin, which was approved last May, costs $5,300 for two doses; and oritavancin, which was approved last August, costs $3,400 for one dose.

The arguments for using these newer drugs “may be that you can discharge the patient home, assuming they’ll have an active antibiotic in their system for a week, and maybe that will be more cost-effective,” Dr. Sullivan said. “The role that these should play in the management of your inpatients is still not clear, but they’re very new and interesting developments in treatment.” TH

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