Clinical

Clostridium difficile infection (CDI) is a common and costly bacterial illness in hospitalized patients, involving 1% of U.S. hospital stays with an aggregate cost of $8.2 billion annually.¹ The spore-forming, gram-positive bacillus is spread by the fecal-oral route; in health-care settings, it is often transmitted by hand carriage and contamination of environmental surfaces. C. diff produces toxins that can cause a spectrum of diseases, including asymptomatic carriage, mild to severe diarrhea, colitis, and pseudomembranous colitis, which in severe cases can lead to sepsis, colectomy, or death.

CDI is defined as the acute onset of diarrhea in a patient with documented toxigenic C. diff or C. diff toxin, without any other clear cause of diarrhea.² In the past decade, CDI has increased in frequency and severity, with most experts thinking it is related to a particularly virulent strain known as BI/NAP1/027.3 Antibiotic exposure is the most significant and modifiable risk factor for CDI, with increasing age, gastric acid suppression, and immunocompromised states also placing patients at increased risk for developing infection.

Guideline Analysis

In February, the American College of Gastroenterology (ACG) released guidelines for diagnostic testing and pharmacologic therapy for CDI, management of complicated and recurrent disease, and infection control and prevention.² Previous recommendations for the prevention, diagnosis, and treatment of CDI have been provided by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and a collaboration of the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).^4,5 Recommendations addressing CDI in infants and children are also available.⁶ The 2013 ACG guidelines are the first from this group to address CDI and are intended to supplement previously published guidelines.

Diagnostic testing. The ACG guidelines emphasize that only stools from patients with diarrhea be tested for C. diff and/or its toxin. Colonization with C. diff is common, and performing tests in asymptomatic patients may complicate clinical care. Rarely, patients with CDI will develop ileus, and in those cases, rectal swab may be performed, but in nearly all circumstances, only diarrheal stools warrant testing. The authors also strongly discourage repeat testing after a negative test and testing for cure following treatment and resolution of symptoms. All of these recommendations are consistent with the SHEA-IDSA guidelines and reflect moderate- to high-quality evidence.

Recognizing that diagnostic testing for C. diff continues to evolve, the ACG makes specific recommendations regarding the use of newer tests, such as nucleic acid amplification and glutamate dehydrogenase detection. These are favored over toxin A and B enzyme immunoassay testing due to higher sensitivity.

Management of mild, moderate, and severe CDI. As with prior guidelines, the 2013 ACG guidelines stratify treatment recommendations by disease severity. Mild to moderate disease, which includes diarrhea only (mild) or diarrhea with signs and symptoms not meeting criteria for severe or complicated CDI (moderate), should be treated with metronidazole 500 mg orally three times daily for 10 days. Oral vancomycin should only be used in patients with mild to moderate disease who fail to respond after five to seven days of metronidazole or in those who are intolerant to metronidazole, or pregnant or breastfeeding. Although fidaxomicin is FDA-approved to treat mild to moderate CDI, the ACG does not make a formal recommendation on its use, given its high cost and limited data to support its effectiveness.

The ACG defines severe disease as CDI in patients with albumin <3 g/dL, and either WBC ≥15,000 cells/mm3 or abdominal tenderness. Though this definition of severe disease differs from the ESCMID and SHEA-IDSA definitions, which include elevated creatinine (>50% greater than premorbid level) instead of low albumin, the treatment recommendation is the same: vancomycin 125 mg orally four times daily for 10 days. While vancomycin and metronidazole are equally effective in mild to moderate CDI, there is some evidence to suggest that vancomycin is more effective in severe disease.⁷

Regardless of disease severity, one of the strongest recommendations is to discontinue any inciting antibiotics. This point, along with the recommendation to avoid anti-peristaltic agents, has also been emphasized in prior guidelines. Additionally, the authors note that although providers commonly prescribe treatment for 14 days, there is no evidence to suggest that a 14-day treatment course is more efficacious than a 10-day course for either metronidazole or vancomycin.

Management of severe and complicated CDI. Severe and complicated disease refers to CDI in patients meeting at least one of the following criteria: admission to the ICU, hypotension, fever ≥38.5°C, ileus or significant abdominal distention, mental status changes, WBC ≥35,000 or <2,000 cells/mm3, serum lactate >2.2 mmol/L, or end-stage organ failure. This definition is more specific than the SHEA-IDSA guidelines, which categorize severe and complicated disease as situations where shock, ileus, or megacolon are present. The recommended treatment is combined therapy with oral vancomycin 125 mg four times daily, plus intravenous metronidazole 500 mg three times daily. Surgical consultation should be obtained in all patients with complicated CDI. Colectomy should be considered in patients with evidence of severe sepsis, leukocytosis of ≥50,000, lactate ≥5 mmol/L, and failure to improve with medical therapy.

Patients with ileus or history of bowel surgery in whom oral antibiotics may not reach the colon should have vancomycin per rectum (enema of 500 mg in 100 mL to 500 mL of normal saline every six hours) added to the above treatments, regardless of disease severity.

Management of recurrent CDI. Consistent with previously published guidelines, the ACG recommends that the first recurrence of CDI be treated with the same regimen that was used for the initial episode. Second recurrences should be treated with a pulsed oral vancomycin regimen. Data are lacking regarding specific taper regimens, but the ACG suggests vancomycin 125 mg four times daily for 10 days, followed by a 125 mg dose every three days for 10 doses. For additional recurrences, fecal microbiota transplant may be considered. Reports suggest that this practice is safe and effective, but data from randomized controlled trials are lacking.

There is limited evidence to support the use of other antibiotics (e.g. rifampin, rifamixin), probiotics, or immunotherapy in the prevention of recurrent CDI.

Management of CDI in patients with comorbid conditions. A unique feature of the 2013 ACG guidelines is the incorporation of recommendations for patient groups who are at elevated risk for developing CDI or associated complications. Patients with inflammatory bowel disease (IBD) are one such group, as they often have underlying colonic inflammation and ongoing immunosuppression. The authors recommend that patients presenting with IBD flares be tested for C. diff. Other immunocompromised populations, including patients with malignancy, exposure to chemotherapy or corticosteroids, organ transplantation, and cirrhosis, should also be tested for CDI when presenting with diarrheal illness. Similarly, pregnant and peripartum women are considered high-risk and should undergo early testing and prompt initiation of treatment for CDI in the setting of diarrhea.

Infection control and prevention. Like SHEA-IDSA, the ACG recommends a hospital-based infection control program, antibiotic stewardship, and strict use of contact precautions for patients with known or suspected CDI. Contact precautions should be continued at minimum for the duration of diarrhea. Patients should be placed in private rooms and disposable equipment should be used, when possible. Disinfection of environmental surfaces is critical, as the environment is a common source of nosocomial infection. Disinfectants should have an Environmental Protection Agency-registered C. diff sporicidal label claim or contain a minimum concentration of chlorine solution. Important: Hand-washing with soap and water is required, as alcohol-based antiseptics are not active against C. diff spores.

HM Takeaways

The 2013 ACG guidelines for the diagnosis, treatment, and prevention of CDI are generally consistent with previously published guidelines from ESCMID and SHEA-IDSA. Ongoing points of emphasis are the following:

1. Only test patients with diarrhea;
2. Do not repeat testing after a negative test or after completion of treatment;
3. Promptly discontinue any inciting antibiotics;
4. Avoid use of anti-peristaltic agents; and
5. Treat based on disease severity.

Hospitalists should be aware of criteria that place patients into the severe and complicated category, and understand that initial treatment should be provided for a 10-day course. These guidelines also highlight the need for a high index of suspicion and low threshold for empiric treatment in immunocompromised patients.

Finally, hospitalists should be attentive to antibiotic stewardship and strictly adhere to contact precautions and hand hygiene with soap and water, as these behaviors have been shown to prevent and control CDI.

Dr. Cunningham Sponsler is a hospitalist in the section of hospital medicine at Vanderbilt University in Nashville, Tenn.

References

1. Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf. Accessed June 17, 2013.

2. Surawicz CM, Brandt LJ, Binion DJ, et al. Guidelines for diagnosis, treatment and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478-498.

3. Freeman J, Bauer MP, Baines SD, et al. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev. 2010;23:529-549.

4. Bauer MP, Kuijper EJ, van Dissel JT. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance for Clostridium difficile infection (CDI). Clin Microbiol Infect. 2009;15:1067-1079.

5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control and Hosp Epidemiol. 2010;31:431-455.

6. Committee on Infectious Diseases. Clostridium difficile infection in infants and children. Pediatrics. 2013;131:196-200.

7. Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-307.

Clostridium difficile infection (CDI) is a common and costly bacterial illness in hospitalized patients, involving 1% of U.S. hospital stays with an aggregate cost of $8.2 billion annually.¹ The spore-forming, gram-positive bacillus is spread by the fecal-oral route; in health-care settings, it is often transmitted by hand carriage and contamination of environmental surfaces. C. diff produces toxins that can cause a spectrum of diseases, including asymptomatic carriage, mild to severe diarrhea, colitis, and pseudomembranous colitis, which in severe cases can lead to sepsis, colectomy, or death.

CDI is defined as the acute onset of diarrhea in a patient with documented toxigenic C. diff or C. diff toxin, without any other clear cause of diarrhea.² In the past decade, CDI has increased in frequency and severity, with most experts thinking it is related to a particularly virulent strain known as BI/NAP1/027.3 Antibiotic exposure is the most significant and modifiable risk factor for CDI, with increasing age, gastric acid suppression, and immunocompromised states also placing patients at increased risk for developing infection.

Guideline Analysis

In February, the American College of Gastroenterology (ACG) released guidelines for diagnostic testing and pharmacologic therapy for CDI, management of complicated and recurrent disease, and infection control and prevention.² Previous recommendations for the prevention, diagnosis, and treatment of CDI have been provided by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and a collaboration of the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).^4,5 Recommendations addressing CDI in infants and children are also available.⁶ The 2013 ACG guidelines are the first from this group to address CDI and are intended to supplement previously published guidelines.

Diagnostic testing. The ACG guidelines emphasize that only stools from patients with diarrhea be tested for C. diff and/or its toxin. Colonization with C. diff is common, and performing tests in asymptomatic patients may complicate clinical care. Rarely, patients with CDI will develop ileus, and in those cases, rectal swab may be performed, but in nearly all circumstances, only diarrheal stools warrant testing. The authors also strongly discourage repeat testing after a negative test and testing for cure following treatment and resolution of symptoms. All of these recommendations are consistent with the SHEA-IDSA guidelines and reflect moderate- to high-quality evidence.

Recognizing that diagnostic testing for C. diff continues to evolve, the ACG makes specific recommendations regarding the use of newer tests, such as nucleic acid amplification and glutamate dehydrogenase detection. These are favored over toxin A and B enzyme immunoassay testing due to higher sensitivity.

Management of mild, moderate, and severe CDI. As with prior guidelines, the 2013 ACG guidelines stratify treatment recommendations by disease severity. Mild to moderate disease, which includes diarrhea only (mild) or diarrhea with signs and symptoms not meeting criteria for severe or complicated CDI (moderate), should be treated with metronidazole 500 mg orally three times daily for 10 days. Oral vancomycin should only be used in patients with mild to moderate disease who fail to respond after five to seven days of metronidazole or in those who are intolerant to metronidazole, or pregnant or breastfeeding. Although fidaxomicin is FDA-approved to treat mild to moderate CDI, the ACG does not make a formal recommendation on its use, given its high cost and limited data to support its effectiveness.

The ACG defines severe disease as CDI in patients with albumin <3 g/dL, and either WBC ≥15,000 cells/mm3 or abdominal tenderness. Though this definition of severe disease differs from the ESCMID and SHEA-IDSA definitions, which include elevated creatinine (>50% greater than premorbid level) instead of low albumin, the treatment recommendation is the same: vancomycin 125 mg orally four times daily for 10 days. While vancomycin and metronidazole are equally effective in mild to moderate CDI, there is some evidence to suggest that vancomycin is more effective in severe disease.⁷

Regardless of disease severity, one of the strongest recommendations is to discontinue any inciting antibiotics. This point, along with the recommendation to avoid anti-peristaltic agents, has also been emphasized in prior guidelines. Additionally, the authors note that although providers commonly prescribe treatment for 14 days, there is no evidence to suggest that a 14-day treatment course is more efficacious than a 10-day course for either metronidazole or vancomycin.

Management of severe and complicated CDI. Severe and complicated disease refers to CDI in patients meeting at least one of the following criteria: admission to the ICU, hypotension, fever ≥38.5°C, ileus or significant abdominal distention, mental status changes, WBC ≥35,000 or <2,000 cells/mm3, serum lactate >2.2 mmol/L, or end-stage organ failure. This definition is more specific than the SHEA-IDSA guidelines, which categorize severe and complicated disease as situations where shock, ileus, or megacolon are present. The recommended treatment is combined therapy with oral vancomycin 125 mg four times daily, plus intravenous metronidazole 500 mg three times daily. Surgical consultation should be obtained in all patients with complicated CDI. Colectomy should be considered in patients with evidence of severe sepsis, leukocytosis of ≥50,000, lactate ≥5 mmol/L, and failure to improve with medical therapy.

Patients with ileus or history of bowel surgery in whom oral antibiotics may not reach the colon should have vancomycin per rectum (enema of 500 mg in 100 mL to 500 mL of normal saline every six hours) added to the above treatments, regardless of disease severity.

Management of recurrent CDI. Consistent with previously published guidelines, the ACG recommends that the first recurrence of CDI be treated with the same regimen that was used for the initial episode. Second recurrences should be treated with a pulsed oral vancomycin regimen. Data are lacking regarding specific taper regimens, but the ACG suggests vancomycin 125 mg four times daily for 10 days, followed by a 125 mg dose every three days for 10 doses. For additional recurrences, fecal microbiota transplant may be considered. Reports suggest that this practice is safe and effective, but data from randomized controlled trials are lacking.

There is limited evidence to support the use of other antibiotics (e.g. rifampin, rifamixin), probiotics, or immunotherapy in the prevention of recurrent CDI.

Management of CDI in patients with comorbid conditions. A unique feature of the 2013 ACG guidelines is the incorporation of recommendations for patient groups who are at elevated risk for developing CDI or associated complications. Patients with inflammatory bowel disease (IBD) are one such group, as they often have underlying colonic inflammation and ongoing immunosuppression. The authors recommend that patients presenting with IBD flares be tested for C. diff. Other immunocompromised populations, including patients with malignancy, exposure to chemotherapy or corticosteroids, organ transplantation, and cirrhosis, should also be tested for CDI when presenting with diarrheal illness. Similarly, pregnant and peripartum women are considered high-risk and should undergo early testing and prompt initiation of treatment for CDI in the setting of diarrhea.

Infection control and prevention. Like SHEA-IDSA, the ACG recommends a hospital-based infection control program, antibiotic stewardship, and strict use of contact precautions for patients with known or suspected CDI. Contact precautions should be continued at minimum for the duration of diarrhea. Patients should be placed in private rooms and disposable equipment should be used, when possible. Disinfection of environmental surfaces is critical, as the environment is a common source of nosocomial infection. Disinfectants should have an Environmental Protection Agency-registered C. diff sporicidal label claim or contain a minimum concentration of chlorine solution. Important: Hand-washing with soap and water is required, as alcohol-based antiseptics are not active against C. diff spores.

HM Takeaways

The 2013 ACG guidelines for the diagnosis, treatment, and prevention of CDI are generally consistent with previously published guidelines from ESCMID and SHEA-IDSA. Ongoing points of emphasis are the following:

1. Only test patients with diarrhea;
2. Do not repeat testing after a negative test or after completion of treatment;
3. Promptly discontinue any inciting antibiotics;
4. Avoid use of anti-peristaltic agents; and
5. Treat based on disease severity.

Hospitalists should be aware of criteria that place patients into the severe and complicated category, and understand that initial treatment should be provided for a 10-day course. These guidelines also highlight the need for a high index of suspicion and low threshold for empiric treatment in immunocompromised patients.

Finally, hospitalists should be attentive to antibiotic stewardship and strictly adhere to contact precautions and hand hygiene with soap and water, as these behaviors have been shown to prevent and control CDI.

Dr. Cunningham Sponsler is a hospitalist in the section of hospital medicine at Vanderbilt University in Nashville, Tenn.

References

1. Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf. Accessed June 17, 2013.

2. Surawicz CM, Brandt LJ, Binion DJ, et al. Guidelines for diagnosis, treatment and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478-498.

3. Freeman J, Bauer MP, Baines SD, et al. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev. 2010;23:529-549.

4. Bauer MP, Kuijper EJ, van Dissel JT. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance for Clostridium difficile infection (CDI). Clin Microbiol Infect. 2009;15:1067-1079.

5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control and Hosp Epidemiol. 2010;31:431-455.

6. Committee on Infectious Diseases. Clostridium difficile infection in infants and children. Pediatrics. 2013;131:196-200.

7. Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-307.

Clostridium difficile infection (CDI) is a common and costly bacterial illness in hospitalized patients, involving 1% of U.S. hospital stays with an aggregate cost of $8.2 billion annually.¹ The spore-forming, gram-positive bacillus is spread by the fecal-oral route; in health-care settings, it is often transmitted by hand carriage and contamination of environmental surfaces. C. diff produces toxins that can cause a spectrum of diseases, including asymptomatic carriage, mild to severe diarrhea, colitis, and pseudomembranous colitis, which in severe cases can lead to sepsis, colectomy, or death.

CDI is defined as the acute onset of diarrhea in a patient with documented toxigenic C. diff or C. diff toxin, without any other clear cause of diarrhea.² In the past decade, CDI has increased in frequency and severity, with most experts thinking it is related to a particularly virulent strain known as BI/NAP1/027.3 Antibiotic exposure is the most significant and modifiable risk factor for CDI, with increasing age, gastric acid suppression, and immunocompromised states also placing patients at increased risk for developing infection.

Guideline Analysis

In February, the American College of Gastroenterology (ACG) released guidelines for diagnostic testing and pharmacologic therapy for CDI, management of complicated and recurrent disease, and infection control and prevention.² Previous recommendations for the prevention, diagnosis, and treatment of CDI have been provided by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and a collaboration of the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).^4,5 Recommendations addressing CDI in infants and children are also available.⁶ The 2013 ACG guidelines are the first from this group to address CDI and are intended to supplement previously published guidelines.

Diagnostic testing. The ACG guidelines emphasize that only stools from patients with diarrhea be tested for C. diff and/or its toxin. Colonization with C. diff is common, and performing tests in asymptomatic patients may complicate clinical care. Rarely, patients with CDI will develop ileus, and in those cases, rectal swab may be performed, but in nearly all circumstances, only diarrheal stools warrant testing. The authors also strongly discourage repeat testing after a negative test and testing for cure following treatment and resolution of symptoms. All of these recommendations are consistent with the SHEA-IDSA guidelines and reflect moderate- to high-quality evidence.

Recognizing that diagnostic testing for C. diff continues to evolve, the ACG makes specific recommendations regarding the use of newer tests, such as nucleic acid amplification and glutamate dehydrogenase detection. These are favored over toxin A and B enzyme immunoassay testing due to higher sensitivity.

Management of mild, moderate, and severe CDI. As with prior guidelines, the 2013 ACG guidelines stratify treatment recommendations by disease severity. Mild to moderate disease, which includes diarrhea only (mild) or diarrhea with signs and symptoms not meeting criteria for severe or complicated CDI (moderate), should be treated with metronidazole 500 mg orally three times daily for 10 days. Oral vancomycin should only be used in patients with mild to moderate disease who fail to respond after five to seven days of metronidazole or in those who are intolerant to metronidazole, or pregnant or breastfeeding. Although fidaxomicin is FDA-approved to treat mild to moderate CDI, the ACG does not make a formal recommendation on its use, given its high cost and limited data to support its effectiveness.

The ACG defines severe disease as CDI in patients with albumin <3 g/dL, and either WBC ≥15,000 cells/mm3 or abdominal tenderness. Though this definition of severe disease differs from the ESCMID and SHEA-IDSA definitions, which include elevated creatinine (>50% greater than premorbid level) instead of low albumin, the treatment recommendation is the same: vancomycin 125 mg orally four times daily for 10 days. While vancomycin and metronidazole are equally effective in mild to moderate CDI, there is some evidence to suggest that vancomycin is more effective in severe disease.⁷

Regardless of disease severity, one of the strongest recommendations is to discontinue any inciting antibiotics. This point, along with the recommendation to avoid anti-peristaltic agents, has also been emphasized in prior guidelines. Additionally, the authors note that although providers commonly prescribe treatment for 14 days, there is no evidence to suggest that a 14-day treatment course is more efficacious than a 10-day course for either metronidazole or vancomycin.

Management of severe and complicated CDI. Severe and complicated disease refers to CDI in patients meeting at least one of the following criteria: admission to the ICU, hypotension, fever ≥38.5°C, ileus or significant abdominal distention, mental status changes, WBC ≥35,000 or <2,000 cells/mm3, serum lactate >2.2 mmol/L, or end-stage organ failure. This definition is more specific than the SHEA-IDSA guidelines, which categorize severe and complicated disease as situations where shock, ileus, or megacolon are present. The recommended treatment is combined therapy with oral vancomycin 125 mg four times daily, plus intravenous metronidazole 500 mg three times daily. Surgical consultation should be obtained in all patients with complicated CDI. Colectomy should be considered in patients with evidence of severe sepsis, leukocytosis of ≥50,000, lactate ≥5 mmol/L, and failure to improve with medical therapy.

Patients with ileus or history of bowel surgery in whom oral antibiotics may not reach the colon should have vancomycin per rectum (enema of 500 mg in 100 mL to 500 mL of normal saline every six hours) added to the above treatments, regardless of disease severity.

Management of recurrent CDI. Consistent with previously published guidelines, the ACG recommends that the first recurrence of CDI be treated with the same regimen that was used for the initial episode. Second recurrences should be treated with a pulsed oral vancomycin regimen. Data are lacking regarding specific taper regimens, but the ACG suggests vancomycin 125 mg four times daily for 10 days, followed by a 125 mg dose every three days for 10 doses. For additional recurrences, fecal microbiota transplant may be considered. Reports suggest that this practice is safe and effective, but data from randomized controlled trials are lacking.

There is limited evidence to support the use of other antibiotics (e.g. rifampin, rifamixin), probiotics, or immunotherapy in the prevention of recurrent CDI.

Management of CDI in patients with comorbid conditions. A unique feature of the 2013 ACG guidelines is the incorporation of recommendations for patient groups who are at elevated risk for developing CDI or associated complications. Patients with inflammatory bowel disease (IBD) are one such group, as they often have underlying colonic inflammation and ongoing immunosuppression. The authors recommend that patients presenting with IBD flares be tested for C. diff. Other immunocompromised populations, including patients with malignancy, exposure to chemotherapy or corticosteroids, organ transplantation, and cirrhosis, should also be tested for CDI when presenting with diarrheal illness. Similarly, pregnant and peripartum women are considered high-risk and should undergo early testing and prompt initiation of treatment for CDI in the setting of diarrhea.

Infection control and prevention. Like SHEA-IDSA, the ACG recommends a hospital-based infection control program, antibiotic stewardship, and strict use of contact precautions for patients with known or suspected CDI. Contact precautions should be continued at minimum for the duration of diarrhea. Patients should be placed in private rooms and disposable equipment should be used, when possible. Disinfection of environmental surfaces is critical, as the environment is a common source of nosocomial infection. Disinfectants should have an Environmental Protection Agency-registered C. diff sporicidal label claim or contain a minimum concentration of chlorine solution. Important: Hand-washing with soap and water is required, as alcohol-based antiseptics are not active against C. diff spores.

HM Takeaways

The 2013 ACG guidelines for the diagnosis, treatment, and prevention of CDI are generally consistent with previously published guidelines from ESCMID and SHEA-IDSA. Ongoing points of emphasis are the following:

1. Only test patients with diarrhea;
2. Do not repeat testing after a negative test or after completion of treatment;
3. Promptly discontinue any inciting antibiotics;
4. Avoid use of anti-peristaltic agents; and
5. Treat based on disease severity.

Hospitalists should be aware of criteria that place patients into the severe and complicated category, and understand that initial treatment should be provided for a 10-day course. These guidelines also highlight the need for a high index of suspicion and low threshold for empiric treatment in immunocompromised patients.

Finally, hospitalists should be attentive to antibiotic stewardship and strictly adhere to contact precautions and hand hygiene with soap and water, as these behaviors have been shown to prevent and control CDI.

Dr. Cunningham Sponsler is a hospitalist in the section of hospital medicine at Vanderbilt University in Nashville, Tenn.

References

1. Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf. Accessed June 17, 2013.

2. Surawicz CM, Brandt LJ, Binion DJ, et al. Guidelines for diagnosis, treatment and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478-498.

3. Freeman J, Bauer MP, Baines SD, et al. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev. 2010;23:529-549.

4. Bauer MP, Kuijper EJ, van Dissel JT. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance for Clostridium difficile infection (CDI). Clin Microbiol Infect. 2009;15:1067-1079.

5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control and Hosp Epidemiol. 2010;31:431-455.

6. Committee on Infectious Diseases. Clostridium difficile infection in infants and children. Pediatrics. 2013;131:196-200.

7. Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-307.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to wwch@ucsd.edu.

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to wwch@ucsd.edu.

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to wwch@ucsd.edu.

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.

Clinical question: Is the use of proton-pump inhibitors (PPIs) associated with risk of mortality or combined risk of death or rehospitalization in older patients discharged from acute-care hospitals?

Background: Previous studies have shown that the use of PPIs could be associated with increased mortality in institutionalized older people and in patients discharged from acute-care hospitals. Older patients could be more vulnerable to adverse effects of PPIs, such as drug-drug interactions and absorption of nutrients, because of the higher incidence of polypharmacy and malnutrition in the elderly.

Study design: Prospective cohort.

Setting: Eleven acute-care medical wards participating in the Italian study Pharmacosurveillance in the Elderly Care.

Synopsis: All patients aged 65 years or older consecutively admitted to participating wards from April to June 2007 underwent screening. Excluding patients who refused, died during hospitalization, or were admitted to long-term care or rehabilitation units, a total of 491 patients were analyzed. The study team administered questionnaires during admission and conducted follow-up visits every three months for one year after discharge. Outcomes included one-year survival of patients discharged from acute-care medical wards and the combined endpoint of death or rehospitalization.

Overall, 174 patients (35.4%) had PPI exposure. After adjusting for age, cognitive impairment, disability, comorbidities, nutritional status, and number of drugs prescribed, patients exposed to PPIs had a significantly increased risk of death (adjusted HR 1.51, 95% CI 1.03-2.77). This association was strongest among patients receiving high-dose PPIs. No such association was found when considering the combined endpoint (HR 1.49, 95% CI 0.98-2.17). Limitations of the study include observational design, small size, potential for confounding by indication for PPI, and indeterminate PPI use prior to index hospitalization. Finally, the finding of an association between PPIs and increased mortality does not equate to a causative relationship between the two variables.

Bottom line: Proton-pump inhibitor use in older patients discharged from acute-care hospitals is associated with increased all-cause mortality at one year.

Citation: Maggio M, Corsonello A, Ceda GP, et al. Proton-pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals. JAMA Intern Med. 2013;173(7):518-523.

Clinical question: Is the use of proton-pump inhibitors (PPIs) associated with risk of mortality or combined risk of death or rehospitalization in older patients discharged from acute-care hospitals?

Background: Previous studies have shown that the use of PPIs could be associated with increased mortality in institutionalized older people and in patients discharged from acute-care hospitals. Older patients could be more vulnerable to adverse effects of PPIs, such as drug-drug interactions and absorption of nutrients, because of the higher incidence of polypharmacy and malnutrition in the elderly.

Study design: Prospective cohort.

Setting: Eleven acute-care medical wards participating in the Italian study Pharmacosurveillance in the Elderly Care.

Synopsis: All patients aged 65 years or older consecutively admitted to participating wards from April to June 2007 underwent screening. Excluding patients who refused, died during hospitalization, or were admitted to long-term care or rehabilitation units, a total of 491 patients were analyzed. The study team administered questionnaires during admission and conducted follow-up visits every three months for one year after discharge. Outcomes included one-year survival of patients discharged from acute-care medical wards and the combined endpoint of death or rehospitalization.

Overall, 174 patients (35.4%) had PPI exposure. After adjusting for age, cognitive impairment, disability, comorbidities, nutritional status, and number of drugs prescribed, patients exposed to PPIs had a significantly increased risk of death (adjusted HR 1.51, 95% CI 1.03-2.77). This association was strongest among patients receiving high-dose PPIs. No such association was found when considering the combined endpoint (HR 1.49, 95% CI 0.98-2.17). Limitations of the study include observational design, small size, potential for confounding by indication for PPI, and indeterminate PPI use prior to index hospitalization. Finally, the finding of an association between PPIs and increased mortality does not equate to a causative relationship between the two variables.

Bottom line: Proton-pump inhibitor use in older patients discharged from acute-care hospitals is associated with increased all-cause mortality at one year.

Citation: Maggio M, Corsonello A, Ceda GP, et al. Proton-pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals. JAMA Intern Med. 2013;173(7):518-523.

Clinical question: Is the use of proton-pump inhibitors (PPIs) associated with risk of mortality or combined risk of death or rehospitalization in older patients discharged from acute-care hospitals?

Background: Previous studies have shown that the use of PPIs could be associated with increased mortality in institutionalized older people and in patients discharged from acute-care hospitals. Older patients could be more vulnerable to adverse effects of PPIs, such as drug-drug interactions and absorption of nutrients, because of the higher incidence of polypharmacy and malnutrition in the elderly.

Study design: Prospective cohort.

Setting: Eleven acute-care medical wards participating in the Italian study Pharmacosurveillance in the Elderly Care.

Synopsis: All patients aged 65 years or older consecutively admitted to participating wards from April to June 2007 underwent screening. Excluding patients who refused, died during hospitalization, or were admitted to long-term care or rehabilitation units, a total of 491 patients were analyzed. The study team administered questionnaires during admission and conducted follow-up visits every three months for one year after discharge. Outcomes included one-year survival of patients discharged from acute-care medical wards and the combined endpoint of death or rehospitalization.

Overall, 174 patients (35.4%) had PPI exposure. After adjusting for age, cognitive impairment, disability, comorbidities, nutritional status, and number of drugs prescribed, patients exposed to PPIs had a significantly increased risk of death (adjusted HR 1.51, 95% CI 1.03-2.77). This association was strongest among patients receiving high-dose PPIs. No such association was found when considering the combined endpoint (HR 1.49, 95% CI 0.98-2.17). Limitations of the study include observational design, small size, potential for confounding by indication for PPI, and indeterminate PPI use prior to index hospitalization. Finally, the finding of an association between PPIs and increased mortality does not equate to a causative relationship between the two variables.

Bottom line: Proton-pump inhibitor use in older patients discharged from acute-care hospitals is associated with increased all-cause mortality at one year.

Citation: Maggio M, Corsonello A, Ceda GP, et al. Proton-pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals. JAMA Intern Med. 2013;173(7):518-523.

Clinical question: Does uncontrolled diabetes mellitus increase risk for post-operative complications after elective joint replacement surgery?

Background: Several previous studies suggested that patients with uncontrolled diabetes could be at higher risk of postoperative complications and have worse functional outcomes after joint replacement surgery than patients without diabetes. Preoperative glycemic control is a potentially modifiable risk factor in patients undergoing elective joint replacement surgery. Demand for elective joint replacement is expected to increase over time, and reducing the risk of postoperative complications is essential in order to optimize functional outcomes and reduce healthcare costs.

Study design: Retrospective cohort.

Setting: Five regions of the Kaiser Permanente healthcare system.

Synopsis: The study included 40,491 patients aged 18 years and older who underwent primary knee replacement between January 2001 and December 2009 in five regions of the Kaiser Permanente system. Patients were identified using the Kaiser Permanente Total Joint Replacement Registry. Clinical information on each patient was collected from two years before the procedure to one year after the procedure using Kaiser Permanente electronic health records. Subjects were classified as nondiabetic (81.3%), diabetic with good glycemic control (12.5%), or diabetic with poor glycemic control (6.2%). Glycemic control status was assessed using the latest hemoglobin A1c (HbA1c) value measured prior to the date of the index surgery, with HbA1c <7.0% defined as good glycemic control. Outcomes included revision arthroplasty, deep infection, DVT or PE, incident myocardial infarction, and rehospitalization.

There was no significant association identified between uncontrolled diabetes and any of the five outcomes.

Limitations of the study include retrospective design, rarity of all outcomes except all-cause rehospitalization, and the small number of patients with uncontrolled diabetes in the cohort. In addition, functional outcomes were not assessed in this study.

Bottom line: The effect of uncontrolled diabetes on the risk of adverse surgical outcomes following elective joint replacement remains unclear based on currently published data; more studies are needed.

Citation: Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001-2009. J Bone Joint Surg Am. 2013;95:481-487.

Clinical question: Does uncontrolled diabetes mellitus increase risk for post-operative complications after elective joint replacement surgery?

Background: Several previous studies suggested that patients with uncontrolled diabetes could be at higher risk of postoperative complications and have worse functional outcomes after joint replacement surgery than patients without diabetes. Preoperative glycemic control is a potentially modifiable risk factor in patients undergoing elective joint replacement surgery. Demand for elective joint replacement is expected to increase over time, and reducing the risk of postoperative complications is essential in order to optimize functional outcomes and reduce healthcare costs.

Study design: Retrospective cohort.

Setting: Five regions of the Kaiser Permanente healthcare system.

Synopsis: The study included 40,491 patients aged 18 years and older who underwent primary knee replacement between January 2001 and December 2009 in five regions of the Kaiser Permanente system. Patients were identified using the Kaiser Permanente Total Joint Replacement Registry. Clinical information on each patient was collected from two years before the procedure to one year after the procedure using Kaiser Permanente electronic health records. Subjects were classified as nondiabetic (81.3%), diabetic with good glycemic control (12.5%), or diabetic with poor glycemic control (6.2%). Glycemic control status was assessed using the latest hemoglobin A1c (HbA1c) value measured prior to the date of the index surgery, with HbA1c <7.0% defined as good glycemic control. Outcomes included revision arthroplasty, deep infection, DVT or PE, incident myocardial infarction, and rehospitalization.

There was no significant association identified between uncontrolled diabetes and any of the five outcomes.

Limitations of the study include retrospective design, rarity of all outcomes except all-cause rehospitalization, and the small number of patients with uncontrolled diabetes in the cohort. In addition, functional outcomes were not assessed in this study.

Bottom line: The effect of uncontrolled diabetes on the risk of adverse surgical outcomes following elective joint replacement remains unclear based on currently published data; more studies are needed.

Citation: Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001-2009. J Bone Joint Surg Am. 2013;95:481-487.

Clinical question: Does uncontrolled diabetes mellitus increase risk for post-operative complications after elective joint replacement surgery?

Background: Several previous studies suggested that patients with uncontrolled diabetes could be at higher risk of postoperative complications and have worse functional outcomes after joint replacement surgery than patients without diabetes. Preoperative glycemic control is a potentially modifiable risk factor in patients undergoing elective joint replacement surgery. Demand for elective joint replacement is expected to increase over time, and reducing the risk of postoperative complications is essential in order to optimize functional outcomes and reduce healthcare costs.

Study design: Retrospective cohort.

Setting: Five regions of the Kaiser Permanente healthcare system.

Synopsis: The study included 40,491 patients aged 18 years and older who underwent primary knee replacement between January 2001 and December 2009 in five regions of the Kaiser Permanente system. Patients were identified using the Kaiser Permanente Total Joint Replacement Registry. Clinical information on each patient was collected from two years before the procedure to one year after the procedure using Kaiser Permanente electronic health records. Subjects were classified as nondiabetic (81.3%), diabetic with good glycemic control (12.5%), or diabetic with poor glycemic control (6.2%). Glycemic control status was assessed using the latest hemoglobin A1c (HbA1c) value measured prior to the date of the index surgery, with HbA1c <7.0% defined as good glycemic control. Outcomes included revision arthroplasty, deep infection, DVT or PE, incident myocardial infarction, and rehospitalization.

There was no significant association identified between uncontrolled diabetes and any of the five outcomes.

Limitations of the study include retrospective design, rarity of all outcomes except all-cause rehospitalization, and the small number of patients with uncontrolled diabetes in the cohort. In addition, functional outcomes were not assessed in this study.

Bottom line: The effect of uncontrolled diabetes on the risk of adverse surgical outcomes following elective joint replacement remains unclear based on currently published data; more studies are needed.

Citation: Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001-2009. J Bone Joint Surg Am. 2013;95:481-487.

Clinical question: Are high plasma lactate levels associated with mortality and clinical deterioration among patients with acute pulmonary embolism (PE)?

Background: Prognostic clinical markers are limited in patients presenting with acute PE, especially among normotensive individuals. Plasma lactate concentration is a marker of tissue hypoperfusion that has been used to risk-stratify patients with sepsis and trauma. It is unknown whether elevated lactate levels predict poor outcomes in acute PE.

Study design: Prospective cohort.

Setting: ED in a large teaching hospital in Italy.

Synopsis: Consecutive adult patients with acute PE diagnosed by spiral computed tomography or lung scan were included. Plasma lactate levels were tested in all patients at presentation, and levels of ≥2 mmol/L were considered abnormal. The primary endpoint was all-cause death within 30 days, and the secondary endpoint was the composite of all-cause death and PE-related clinical deterioration and death.

Of the 270 patients, 81 (30%) had abnormal lactate levels, though only 12 (4.4%) had shock or hypotension. Patients with elevated lactate had higher mortality compared with patients with lower levels (17.3% vs. 1.6%, OR 12.95, 95% CI 3.43-58.73). Plasma lactate ≥2 mmol/L was associated with higher all-cause mortality (HR 11.67, 95% CI 3.32-41.03) and the composite endpoint (HR 8.14, 95% CI 3.83-17.34). This association was independent of the presence of hypotension, right ventricular dysfunction, or elevated troponin.

Limitations include the single study site (which limits generalizability of the findings) and that lactate levels were only checked once (which might not have fully reflected each patient’s clinical picture). The authors suggest that plasma lactate levels might have utility in determining which patients should be treated more aggressively for PE.

Bottom line: In patients presenting with acute PE, elevated plasma lactate levels are associated with increased risk of short-term mortality and morbidity, independent of the presence of hypotension or markers of right ventricular injury.

Citation: Vanni S, Viviani G, Baioni M, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013;61:330-338.

Clinical question: Are high plasma lactate levels associated with mortality and clinical deterioration among patients with acute pulmonary embolism (PE)?

Background: Prognostic clinical markers are limited in patients presenting with acute PE, especially among normotensive individuals. Plasma lactate concentration is a marker of tissue hypoperfusion that has been used to risk-stratify patients with sepsis and trauma. It is unknown whether elevated lactate levels predict poor outcomes in acute PE.

Study design: Prospective cohort.

Setting: ED in a large teaching hospital in Italy.

Synopsis: Consecutive adult patients with acute PE diagnosed by spiral computed tomography or lung scan were included. Plasma lactate levels were tested in all patients at presentation, and levels of ≥2 mmol/L were considered abnormal. The primary endpoint was all-cause death within 30 days, and the secondary endpoint was the composite of all-cause death and PE-related clinical deterioration and death.

Of the 270 patients, 81 (30%) had abnormal lactate levels, though only 12 (4.4%) had shock or hypotension. Patients with elevated lactate had higher mortality compared with patients with lower levels (17.3% vs. 1.6%, OR 12.95, 95% CI 3.43-58.73). Plasma lactate ≥2 mmol/L was associated with higher all-cause mortality (HR 11.67, 95% CI 3.32-41.03) and the composite endpoint (HR 8.14, 95% CI 3.83-17.34). This association was independent of the presence of hypotension, right ventricular dysfunction, or elevated troponin.

Limitations include the single study site (which limits generalizability of the findings) and that lactate levels were only checked once (which might not have fully reflected each patient’s clinical picture). The authors suggest that plasma lactate levels might have utility in determining which patients should be treated more aggressively for PE.

Bottom line: In patients presenting with acute PE, elevated plasma lactate levels are associated with increased risk of short-term mortality and morbidity, independent of the presence of hypotension or markers of right ventricular injury.

Citation: Vanni S, Viviani G, Baioni M, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013;61:330-338.

Clinical question: Are high plasma lactate levels associated with mortality and clinical deterioration among patients with acute pulmonary embolism (PE)?

Background: Prognostic clinical markers are limited in patients presenting with acute PE, especially among normotensive individuals. Plasma lactate concentration is a marker of tissue hypoperfusion that has been used to risk-stratify patients with sepsis and trauma. It is unknown whether elevated lactate levels predict poor outcomes in acute PE.

Study design: Prospective cohort.

Setting: ED in a large teaching hospital in Italy.

Synopsis: Consecutive adult patients with acute PE diagnosed by spiral computed tomography or lung scan were included. Plasma lactate levels were tested in all patients at presentation, and levels of ≥2 mmol/L were considered abnormal. The primary endpoint was all-cause death within 30 days, and the secondary endpoint was the composite of all-cause death and PE-related clinical deterioration and death.

Of the 270 patients, 81 (30%) had abnormal lactate levels, though only 12 (4.4%) had shock or hypotension. Patients with elevated lactate had higher mortality compared with patients with lower levels (17.3% vs. 1.6%, OR 12.95, 95% CI 3.43-58.73). Plasma lactate ≥2 mmol/L was associated with higher all-cause mortality (HR 11.67, 95% CI 3.32-41.03) and the composite endpoint (HR 8.14, 95% CI 3.83-17.34). This association was independent of the presence of hypotension, right ventricular dysfunction, or elevated troponin.

Limitations include the single study site (which limits generalizability of the findings) and that lactate levels were only checked once (which might not have fully reflected each patient’s clinical picture). The authors suggest that plasma lactate levels might have utility in determining which patients should be treated more aggressively for PE.

Bottom line: In patients presenting with acute PE, elevated plasma lactate levels are associated with increased risk of short-term mortality and morbidity, independent of the presence of hypotension or markers of right ventricular injury.

Citation: Vanni S, Viviani G, Baioni M, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013;61:330-338.

Clinical question: How often do inpatient providers report direct communication with outpatient providers, and how is direct communication associated with 30-day readmissions?

Background: Studies have demonstrated that adverse events and errors occurring after hospital discharge can result from poor provider communication between the inpatient and outpatient setting.

Study design: Prospective cohort.

Setting: Johns Hopkins Hospital, Baltimore.

Synopsis: The presence or absence of direct communication between inpatient and outpatient healthcare providers was captured from a required field in an electronic discharge worksheet completed by the discharging physician. Of 6,635 hospitalizations studied, successful direct communication was reported in 36.7% of cases. Predictors of successful direct communication included patients cared for by hospitalists without house staff (OR 1.81, 95% CI 1.59-2.08), high expected 30-day readmission rate (OR 1.18, 95% CI 1.10-1.28), and insurance by Medicare (OR 1.35, 95% CI 1.16-1.56) and private insurance companies (OR 1.35, 95% CI 1.18-1.56). In adjusted analyses, direct communication between the inpatient and outpatient providers was not associated with 30-day readmissions (OR 1.08, 95% CI 0.92-1.26).

There were several limitations in this study. Only the primary team was surveyed; thus, it is not known if consulting providers might have contacted the outpatient providers. Only readmissions to the same medical center were studied, and therefore it is not known if patients were readmitted to other facilities. Additionally, information regarding discharge communication was self-reported, which might have introduced bias.

Bottom line: Self-reported direct communication between inpatient and outpatient providers occurred infrequently and was not associated with 30-day same-hospital readmission.

Citation: Oduyebo I, Lehmann C, Pollack C, et al. Association of self-reported hospital discharge handoffs with 30-day readmissions. JAMA Intern Med. 2013;173:624-629.

Clinical question: How often do inpatient providers report direct communication with outpatient providers, and how is direct communication associated with 30-day readmissions?

Background: Studies have demonstrated that adverse events and errors occurring after hospital discharge can result from poor provider communication between the inpatient and outpatient setting.

Study design: Prospective cohort.

Setting: Johns Hopkins Hospital, Baltimore.

Synopsis: The presence or absence of direct communication between inpatient and outpatient healthcare providers was captured from a required field in an electronic discharge worksheet completed by the discharging physician. Of 6,635 hospitalizations studied, successful direct communication was reported in 36.7% of cases. Predictors of successful direct communication included patients cared for by hospitalists without house staff (OR 1.81, 95% CI 1.59-2.08), high expected 30-day readmission rate (OR 1.18, 95% CI 1.10-1.28), and insurance by Medicare (OR 1.35, 95% CI 1.16-1.56) and private insurance companies (OR 1.35, 95% CI 1.18-1.56). In adjusted analyses, direct communication between the inpatient and outpatient providers was not associated with 30-day readmissions (OR 1.08, 95% CI 0.92-1.26).

There were several limitations in this study. Only the primary team was surveyed; thus, it is not known if consulting providers might have contacted the outpatient providers. Only readmissions to the same medical center were studied, and therefore it is not known if patients were readmitted to other facilities. Additionally, information regarding discharge communication was self-reported, which might have introduced bias.

Bottom line: Self-reported direct communication between inpatient and outpatient providers occurred infrequently and was not associated with 30-day same-hospital readmission.

Citation: Oduyebo I, Lehmann C, Pollack C, et al. Association of self-reported hospital discharge handoffs with 30-day readmissions. JAMA Intern Med. 2013;173:624-629.

Clinical question: How often do inpatient providers report direct communication with outpatient providers, and how is direct communication associated with 30-day readmissions?

Background: Studies have demonstrated that adverse events and errors occurring after hospital discharge can result from poor provider communication between the inpatient and outpatient setting.

Study design: Prospective cohort.

Setting: Johns Hopkins Hospital, Baltimore.

Synopsis: The presence or absence of direct communication between inpatient and outpatient healthcare providers was captured from a required field in an electronic discharge worksheet completed by the discharging physician. Of 6,635 hospitalizations studied, successful direct communication was reported in 36.7% of cases. Predictors of successful direct communication included patients cared for by hospitalists without house staff (OR 1.81, 95% CI 1.59-2.08), high expected 30-day readmission rate (OR 1.18, 95% CI 1.10-1.28), and insurance by Medicare (OR 1.35, 95% CI 1.16-1.56) and private insurance companies (OR 1.35, 95% CI 1.18-1.56). In adjusted analyses, direct communication between the inpatient and outpatient providers was not associated with 30-day readmissions (OR 1.08, 95% CI 0.92-1.26).

There were several limitations in this study. Only the primary team was surveyed; thus, it is not known if consulting providers might have contacted the outpatient providers. Only readmissions to the same medical center were studied, and therefore it is not known if patients were readmitted to other facilities. Additionally, information regarding discharge communication was self-reported, which might have introduced bias.

Bottom line: Self-reported direct communication between inpatient and outpatient providers occurred infrequently and was not associated with 30-day same-hospital readmission.

Citation: Oduyebo I, Lehmann C, Pollack C, et al. Association of self-reported hospital discharge handoffs with 30-day readmissions. JAMA Intern Med. 2013;173:624-629.

Clinical question: In patients who undergo inferior vena cava (IVC) filter placement for venous thromboembolism (VTE) prophylaxis or treatment, what are the associated patient characteristics, indications for placement, complications, retrieval date, and use of concomitant anticoagulant therapy?

Background: Retrievable IVC filters were designed to provide short-term protection from pulmonary embolism but are often left in place indefinitely. Retrievable IVC filters that are not removed can carry significant long-term risks. Further, the use of filters for VTE prophylaxis is controversial, and there are multiple sets of conflicting guidelines for filter insertion provided by various professional groups.

Study design: Retrospective review of IVC filter use over an eight-year period.

Setting: Boston Medical Center.

Synopsis: Medical records from all patients at Boston Medical Center who had a billing code for placement of an IVC filter between August 2003 and February 2011 were manually reviewed. Nine hundred fifty-two medical records were evaluated, of which 679 (71.3%) patients had retrievable IVC filters placed. The most common indications for filter placement were trauma (50.2%), malignancy (15.9%), and bleeding during anticoagulation (11.8%).

In total, 448 patients (47.1%) had filters placed for prophylactic purposes in the absence of documented VTE. Seventy-four patients developed VTE after filter placement; 48.2% of post-filter insertion VTEs occurred in patients who had no VTE prior to the filter; and 89.4% occurred in patients not receiving anticoagulants. An attempt was made to remove 71 of 679 (10.5%) retrievable filters, and 58 (8.5%) attempts were successful. There were 10 serious complications related to mechanical filter failure, including migration or fracture of the filter.

In this study, there was a high volume of filter use by the trauma service; thus, the patient population might be different from the hospital medicine patient population. The study also lacked systematic imaging and follow-up data. Further studies are needed to analyze the risks associated with IVC filter placement.

Bottom line: Use of IVC filters for VTE treatment and prophylaxis, in the context of low filter retrieval rates and lack of appropriate anticoagulant therapy, results in suboptimal outcomes.

Citation: Sarosiek S, Crowther M, Sloan M. Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013;173:513-517.

Clinical question: In patients who undergo inferior vena cava (IVC) filter placement for venous thromboembolism (VTE) prophylaxis or treatment, what are the associated patient characteristics, indications for placement, complications, retrieval date, and use of concomitant anticoagulant therapy?

Background: Retrievable IVC filters were designed to provide short-term protection from pulmonary embolism but are often left in place indefinitely. Retrievable IVC filters that are not removed can carry significant long-term risks. Further, the use of filters for VTE prophylaxis is controversial, and there are multiple sets of conflicting guidelines for filter insertion provided by various professional groups.

Study design: Retrospective review of IVC filter use over an eight-year period.

Setting: Boston Medical Center.

Synopsis: Medical records from all patients at Boston Medical Center who had a billing code for placement of an IVC filter between August 2003 and February 2011 were manually reviewed. Nine hundred fifty-two medical records were evaluated, of which 679 (71.3%) patients had retrievable IVC filters placed. The most common indications for filter placement were trauma (50.2%), malignancy (15.9%), and bleeding during anticoagulation (11.8%).

In total, 448 patients (47.1%) had filters placed for prophylactic purposes in the absence of documented VTE. Seventy-four patients developed VTE after filter placement; 48.2% of post-filter insertion VTEs occurred in patients who had no VTE prior to the filter; and 89.4% occurred in patients not receiving anticoagulants. An attempt was made to remove 71 of 679 (10.5%) retrievable filters, and 58 (8.5%) attempts were successful. There were 10 serious complications related to mechanical filter failure, including migration or fracture of the filter.

In this study, there was a high volume of filter use by the trauma service; thus, the patient population might be different from the hospital medicine patient population. The study also lacked systematic imaging and follow-up data. Further studies are needed to analyze the risks associated with IVC filter placement.

Bottom line: Use of IVC filters for VTE treatment and prophylaxis, in the context of low filter retrieval rates and lack of appropriate anticoagulant therapy, results in suboptimal outcomes.

Citation: Sarosiek S, Crowther M, Sloan M. Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013;173:513-517.

Clinical question: In patients who undergo inferior vena cava (IVC) filter placement for venous thromboembolism (VTE) prophylaxis or treatment, what are the associated patient characteristics, indications for placement, complications, retrieval date, and use of concomitant anticoagulant therapy?

Background: Retrievable IVC filters were designed to provide short-term protection from pulmonary embolism but are often left in place indefinitely. Retrievable IVC filters that are not removed can carry significant long-term risks. Further, the use of filters for VTE prophylaxis is controversial, and there are multiple sets of conflicting guidelines for filter insertion provided by various professional groups.

Study design: Retrospective review of IVC filter use over an eight-year period.

Setting: Boston Medical Center.

Synopsis: Medical records from all patients at Boston Medical Center who had a billing code for placement of an IVC filter between August 2003 and February 2011 were manually reviewed. Nine hundred fifty-two medical records were evaluated, of which 679 (71.3%) patients had retrievable IVC filters placed. The most common indications for filter placement were trauma (50.2%), malignancy (15.9%), and bleeding during anticoagulation (11.8%).

In total, 448 patients (47.1%) had filters placed for prophylactic purposes in the absence of documented VTE. Seventy-four patients developed VTE after filter placement; 48.2% of post-filter insertion VTEs occurred in patients who had no VTE prior to the filter; and 89.4% occurred in patients not receiving anticoagulants. An attempt was made to remove 71 of 679 (10.5%) retrievable filters, and 58 (8.5%) attempts were successful. There were 10 serious complications related to mechanical filter failure, including migration or fracture of the filter.

In this study, there was a high volume of filter use by the trauma service; thus, the patient population might be different from the hospital medicine patient population. The study also lacked systematic imaging and follow-up data. Further studies are needed to analyze the risks associated with IVC filter placement.

Bottom line: Use of IVC filters for VTE treatment and prophylaxis, in the context of low filter retrieval rates and lack of appropriate anticoagulant therapy, results in suboptimal outcomes.

Citation: Sarosiek S, Crowther M, Sloan M. Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013;173:513-517.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005-2009 were reviewed. A postoperative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated. In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005-2009 were reviewed. A postoperative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated. In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Clinical question: How does timing of surgical antibiotic prophylaxis affect risk of postoperative surgical-site infections (SSIs)?

Background: Antibiotic prophylaxis for major surgical procedures has been proven in clinical trials to reduce rates of SSI. The Centers for Medicare & Medicaid Services’ (CMS) Surgical Care Improvement Project (SCIP) has implemented quality metrics to ensure antibiotics are administered within 60 minutes of incision; however, studies have failed to show that a 60-minute pre-incision window is advantageous.

Study design: Retrospective cohort.

Setting: Veterans Affairs hospitals.

Synopsis: Using SCIP and VA Surgical Quality Improvement Program data from 112 VA hospitals, 32,459 cases of hip or knee arthroplasty, colorectal surgery, arterial vascular surgery, and hysterectomy from 2005-2009 were reviewed. A postoperative SSI occurred in 1,497 cases (4.6%). Using several statistical methods, the relationship between timing of prophylactic antibiotic administration and postoperative SSI within 30 days was evaluated. In unadjusted models, higher SSI rates were observed with antibiotic administration more than 60 minutes prior to incision (OR 1.34, 95% CI 1.08-1.66) but not after incision (OR 1.26, 95% CI 0.92-1.72), compared with procedures with antibiotics administered within 60 minutes pre-incision. However, after adjustment for patient, procedure, and antibiotic variables, no significant relationship between timing and SSI was observed (P=0.50 for all specialties).

The study sample was comprised primarily of older men and did not include patients who underwent cardiac procedures, limiting the generalizability of the findings. Nonetheless, the study is the largest of its kind and confirms previous studies that suggest there is no significant relationship between timing of antibiotics and SSI. Prophylactic antibiotics should still be used when indicated; however, using timing of prophylactic antibiotics as a quality measure is unlikely to improve outcomes.

Bottom line: Adherence to the empiric 60-minute window metric for timing of prophylactic antibiotics is not significantly associated with risk of SSI.

Citation: Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013 March 20:1-8. doi: 10.1001/jamasurg.2013.134 [Epub ahead of print].

Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.

Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.

Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.