HM16 Session Analysis: Update in Pulmonary Medicine
Presenter: Daniel D. Dressler, MD, MSc, SFHM
Summary: This presentation focused on pulmonary updates specific to hospitalist practice, from end of 2014 to early 2016.
New research on community-acquired pneumonia suggest that only 38% of cases a presumptive pathogen will be isolated. Virus account for 23%, bacteria 11% (including S. pneumonia, S. Aureus and Enterobacteriaceae), both (virus and bacteria) 3%, and fungus or mycobacterium 1%. It is important to notice no recent data on etiology was available since mid-1990.
There is also a new pragmatic trial suggesting that B-lactam monotherapy is not inferior to either B-lactam in combination with macrolides or fluoroquinolones. The study reported an 11%, 90-day mortality with B-lactam monotherapy compared with 11% when combined with macrolides and 8.8% when using quinolones monotherapy.
Update evidence supports the use of corticosteroids for hospitalized patients with community-acquired pneumonia, at a dose of 20-60 mg day for 5-7 days. The study showed decreased mortality in patients with clinical criteria for severe pneumonia with NNT 7; it also showed decrease need for mechanical ventilation and development of ARDS.
An additional, interesting finding was a decrease in length of stay (LOS) in the steroid group. In patients with acute hypoxemic respiratory failure, high flow nasal cannula reduced mortality and likely reduces intubation in severely hypoxemic patients when compared to NPPV.
In patients with first unprovoked VTE, extending anticoagulation to two years or adding aspirin after initial anticoagulation might reduce recurrent VTE without significant increasing in risk for major bleeding.
Key Takeaways:
- B-lactam monotherapy for hospitalized non-ICU CAP might be reasonable choice.
- Moderate short course of steroids in CAP, reduce ARDS, intubation, LOS in all hospitalized patients (and mortality on severe CAP)
- A trial of high flow NC is indicated in acute hypoxemic respiratory failure
- Aspirin prophylaxis following anticoagulation (most benefit first year), or extended anticoagulation for 2 years reduce recurrent VTE without much additional bleeding risk.
Dr. Villagra is a hospitalist in Batesville, Ark., and a member of Team Hospitalist.