SPEAKER_01 0:19

Hello and welcome to Inpatient Update. I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the working hospitalist. Today on the show, I'm joined by Dr. Austin White as we delve into recent studies on a couple of hospital medicine controversies. Should we be treating asymptomatic hypertension in the hospital? Should we be giving antibiotics to patients admitted with pneumonia and a positive viral panel? Well, Dr. White, thank you so much for being with me here today.

SPEAKER_00 0:49

Thank you. Thank you for having me.

SPEAKER_01 0:50

For the audience, Dr. Austin White is one of my colleagues, a rapidly rising superstar in my division. Another thing of note is uh Dr. White does a lot of nights with us. I'm excited to have a nocturnist's perspective on this or a semi-nocturnist. And in that vein, Austin, have you ever gotten a page overnight from a nurse that says Miss Jones has a blood pressure of systolics of let's go 204? Oh no. Anything in that range sound like something you've ever had to deal with? Every single night.

SPEAKER_00 1:27

Yes. Maybe not that high. That high is a little bit too high. But every night I'm constantly picked.

SPEAKER_01 1:32

What do you do when you get that page? What's what's your go-to response? What's your go-to reaction?

SPEAKER_00 1:36

So whenever I'm chatted that that blood pressure, I always ask, are there any symptoms? And usually it's a no. And we'll move on from there. But um yeah, it's a constant uh question from from nursing.

SPEAKER_01 1:51

Yeah, agreed. I kind of my rule of thumb, honestly, in the way I I genuinely practice is I as long as that first digit isn't a two, I feel pretty comfortable holding the line. I say, let's like restart their home orals, or even I'll say, let's get them started on something a little bit oral just to do something, just to make honestly to make myself a little bit, but mostly everyone else feel a little more comfortable. The patient and the nurse feel a little more comfortable that we're treating it. So I'll usually throw maybe a PO carvatolol and then sort of scheduling it and planning on it forward. I think a lot of our sort of default order sets that you can order as PRNs for hypertension, 180 is usually the number. And I think our order set that like page MD if greater than is probably 180. That's kind of like my so I think of like the default number of like you're getting a page if it's higher than that. And usually the nurses are pretty good about we don't hear from them if it's not more than 180. Speak for yourself depending on the nurse.

SPEAKER_00 2:51

So at night it's definitely a different ball game where um if it reads red and they're in their kind of vital sign sheet, I'll get paged about it usually. So there's a lot of acknowledge the the message for 160, 170, and I'll give a thumbs up. But you know, I have no symptoms. I'm I'm less interested. But at night, you definitely get paged more regarding those numbers.

SPEAKER_01 3:16

And so I I have this discussion because this is one of those things that that I've heard about and has been on my radar for a long time. This is something we treat, we over-treat inpatient hypertension. It ended up as number one on the list of things we do for no reason and the things we do for no reason session at SHM this year. This was their number one thing treating inpatient hypertension with PRNs or one-time meds. And so it's the kind of thing that I I've kind of heard that, I've been aware of that. I hadn't been totally up to date on all the data and then saw this study came out just recently that kind of shined lights on are we just are we just doing it for no reason or are we doing it for no reason and actively harming patients? Which obviously makes a big difference. If we're doing it for no reason and it drops the um blood pressure of the overnight provider and helps save save a page and the nurse and all of that, then it's one thing. But if we're actively harming patients by doing it, it's another. And so that's what the study specifically looked in to try and find. Um, and so this was in published in Jam Internal Medicine, and it was published in 2025. It was entitled As Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals. It was um a retrospective cohort study. What they did is they took patients over multiple years, everyone that got admitted to the hospital, and then they broke things down into patients receiving either one or more PRN antihypertensive versus people who didn't receive any antihypertensive. And the primary outcome they looked at was acute kidney injury, and then a secondary um outcome of two aggressive blood pressure drops. So they looked at how many of the patients got dropped greater than 25% within three hours, and then also a composite outcome of myocardial infarction stroke or death. And so the big headline result was that all of these things were worse in the patients that got the PRNs. So the AKIs were, I think, 23% more likely to have an AKI. Um, there was a hazard ratio of 1.23 that was statistically significant, um, a statistically significant hazard ratio of 1.5 for the rapid drop in blood pressure. And um anytime you've got uh a composite outcome with stroke, heart attack, and dying, I'm gonna be particularly interested. And was also statistically significant, more in the group that got treated with PRNs with a hazard ratio of 1.6. And they looked into the these things a little bit deeper. And IV patients that got IV antihypertensives were even worse, more likely to get an AKI, with the hazard ratio being 1.6 instead of 1.23, versus less, but still significantly significant if they're just getting that oral kind of like me giving if I give just that one time Carvatolol, that would put me in that bucket. Still showed that there was harm there in the primary outcome. Um and so that's sort of the big picture of this. I found it helpful to see numbers that state the patients that are being treated with PRN antihypertensive, one-time antihypertensives for an elevated blood pressure were actually seeing worse outcomes.

SPEAKER_00 6:44

It definitely made me think back on my nights and try to remember did I do something for no reason, potentially cause harm. It's I mean, it's very clear. Um, although it's a retrospective study, it's very clear that giving a one-time blood pressure medication with asymptomatic hypertension causes uh at the very least AKIs and potential harm for patients. It's kind of my main takeaway from this.

SPEAKER_01 7:09

Yeah. Definitely. I it's another one of those times where it's almost like a comfort blanket study. That it's like, it's okay. You're not making things worse by not doing anything. I am with you. You mentioned the fact that it's a retrospective trial. And I do like, I am on board with this. I am on board that we are treating in general almost all of the time, we're treating inpatient hypertension unnecessarily. I'm on board that it's something we do for no reason, but we haven't had that randomized control trial that really proves it. Because one of my problems with the study and looking through this, I'm like, okay, yeah, I get it. We we kind of tried to group patients and and balance them like it was a randomized control tile, essentially control the patients by making sure comorbides were the same in each group and they didn't eliminate very many diagnoses, like people have cardiac stuff, everything. They tried to include a lot of stuff, had a large N. But Austin, patients that have an even higher blood pressure, don't you think they're more likely to get the as-needed treatment? Are people are we kind of just like self-selecting the patients that are otherwise sicker? And and maybe this is correlation, not causation.

SPEAKER_00 8:22

Yeah, I saw that with the 140 to 150, the one that um like if you're treating that number, it's kind of like a no duh, it's gonna cause an AKI. Uh yeah, exactly.

SPEAKER_01 8:33

Yeah, they and I hadn't didn't sort of mention that in the rundown, but they did do sort of a subgroup analysis. And that was the only time I saw that in this study they broke it down to just specific blood pressure groups, and that 140 to 159, which you and I are hardly not even tempted to be treating that, it sounds like from our discussion. If you treat those numbers, then you're dropping people who were already not high. I mean, that's that's almost normal for I'm stressed out and in the hospital or I'm in pain or whatever. Um, if you're treating that with antihypertensive, you're gonna particularly see problems. Now, again, I'm on board, but sort of the contrarian or the I want to be like, is this study itself gonna really change my practice in me? I'm I'm uh I'm a little bit tentative because it's not, it's not a randomized control trial, may have just correlation here. And that's even they said that in the discussion. They're like this basically, they think what this study gives us is more ammo to say someone needs to be doing a randomized control trial that will be the nail in the coffin that can really change practice.

SPEAKER_00 9:36

It and it gives me more ammunition at night, at very least, for for these or if it's below 180, more reassured, like I don't need to treat this.

SPEAKER_01 9:46

Now, obviously, we're not talking about hypertensive emergency. If the patient's got a terrible headache, is having chest pain, is having this bad shortness of breath along with it, if we're seeing or flash pulmonary edema, if we're having an AKI, any of that end organ damage, totally different bucket. You need to be treating that blood pressure. But for the patient that is asymptomatic hypertension, that along with the AHA guidelines, there are new guidelines from 2024, and that's basically do not treat asymptomatic elevated blood pressure acutely. And specifically mentioning treatment should generally be the exception and not the rule. I mentioned that session with the uh the things we do for no reason session at this most recent SA recent SHM conference, and they gave uh a compelling argument. There was, I think it was a 2018 article they put out about things we do for no reading reason treating, acutely treating inpatient hypertension. And a couple of things they mentioned that were somewhat was compelling were there was one outpatient study that they mentioned where essentially it was folks in the office looking to see if they come in and in the office they have a blood pressure of systolic of greater than 180, greater than 200. I think they even went up to they had a cohort that was greater than 220 and looking at if you send those patients to the hospital or you send them home, how likely are they to have a cardiac event? And I think it was the next 30 days. And there was no statistically significant difference between the two. So this person who's at home and you're not treating this number, obviously, you're not treating acutely, um, is doing just as good as the person who came into the hospital. Again, just like your patient, if you've got a patient who's otherwise healthy and he's here for a leg fracture and he's just in terrible pain, the takeaway is he's probably gonna do fine. If he was at home, he'd be have that blood pressure probably, and he'd be doing fine. And so we can pretty much ignore that number and just instead treat the underlying cause, like let's be treating this patient's pain.

SPEAKER_00 11:42

And that also kind of patients that come in, they're hypertensive, we'll get calls to admit them all the time at night. And I have to think back, and I'm tempted just because the number is scary, but then I think back to my outpatient days as a resident, and I say, Well, I've had patients that are that high, and I start them on a blood pressure medication, and if they're asymptomatic, we send them home. Right. I I don't know, I don't recommend they go to the emergency department. So it kind of makes you think back on your practice as well at night and say, Oh, maybe I didn't need to treat that number.

SPEAKER_01 12:14

Another kind of interesting point they made that I think as much as anything calmed me down. They made a couple of points. One was there had been a test where I presume they did this with an A-line, where they put a bunch of fit guys, let them loose in a gym, and measured their blood pressure during weight lifting. I don't know. I don't I don't know the mechanisms up here. I don't know if they're just like sitting there right by interesting. And then, like, if it's an A-line, if they're doing because I think one of these was uh doing squats and or no, they did leg press. So maybe they kept their heart at the same level. Um but these these guys, their blood pressures in a curl reached up to 240 over 160, and when they did leg presses, it would reach up to 325 over 245. So these blood pressures are crazy high. And the point, like the point being your body is made to temporarily withstand very high blood pressure, they do it physiologically. Um and so it's not something that's gonna cause a problem for us in certainly minutes or even hours. Obviously, we know long-term management of hypertension is incredibly important, but short term, the body is able to manage it. And another thing they did was showed us some like cerebral blood flow curves and how they really plateaued, and no matter how much higher, how much higher the blood pressure was getting, the cerebral blood flow was pretty constant. But then once you start to overcorrect that blood pressure, it drops off a cliff. And so explaining some, what are these bad outcomes? If you're dropping that blood pressure, then you're dropping them off the curve where then they're not perfusing their brain. Um, and so you're certainly causing more harm than good most of the time, particularly if you've got a patient you don't have any reason to think they can't tolerate that high blood pressure. They should be able to tolerate crazy high numbers. Um, though I don't think any of us are letting a 325 over 245.

SPEAKER_00 14:10

No. It's it's yeah, it's where I think we're all kind of starting to find that we shouldn't be treating these blood pressures. It's just gonna have to take a lot of teaching and reassurance from for both providers as well as with staff and patients and kind of flipping that narrative of no, no, we don't need to treat these. And we've got more data that will need to be obtained in order to really make these big, these big cultural shifts.

SPEAKER_01 14:37

And I do think, I mean, if anyone's out there and and is starting to organize or can get the randomized control trial organized, that would, I think, change everything and how well we can sell this on an institutional level and really change order sets, change institutional policies, change culture with nurses confidently tell patients because it's a tough fight to fight, and we need that fully definitive data. All right. So what do you think? Is this gonna change the practice going forward? And if so, how?

SPEAKER_00 15:06

Overall, yes. It'll make me reassured for under 180. We don't need to do anything. Keep steady. And I, you know, this gives me a little bit more ammunition and more comfortability to say above 180 as well, just you know, have let it ride at night and come up with a better plan daytime if we think that we've um eliminated all other sources of potential hypertension. And hopefully, yes, it'll change my practice for the better.

SPEAKER_01 15:33

If anything, start start something light and world going forward and keep my eyes open for that randomized controlled trial that can can put a nail in this coffin and and really change culture.

SPEAKER_00 15:48

Next thing, kind of keeping with the things maybe we do for no reason. So this is a article called Associations Between Antibiotic Use and Outcomes in Patients Hospitalized with Community Acquired Pneumonia, but with positive respiratory viral assays. So this was a really cool article that infectious disease seem to have done in response to ATS, uh, American Thoracic Society. And I like it when you've got two different societies that don't agree, and then one of them decides to try to prove the other wrong and kind of clap back with it. So it it came in response to ATS guidelines who recommended to treat with antibiotics, even if there was a positive viral assay, claiming that it would decrease mortality, decrease poor outcomes because of the rate of they felt that there was a high rate of bacterial coinfection with these um with these viruses. But infectious disease seemed to disagree and they endorsed more low coinfection rates, um, as well as there's no such thing as a safe medication, including antibiotics. All these things had adverse um events, and that can include AKI, um drug rash, etc. Um, so this um this article was a again a retrospective um multi-center five hospital study over um many years, 2015 to 2024. Um, and there they uh they sought out patients that had a positive um respiratory viral assay within the first 48 hours of them being admitted, and then had clinical signs of pneumonia. So tachynea, hypoxia, chest imaging that was concerning for pneumonia. And then they decided to see whether or not antibiotics made a difference in their in their uh clinical course from either a very short antibiotic of zero to one day, or full uh cap treatment, which is five to seven days. And the headline here was it didn't make a difference. You could not treat them with antibiotics, or you could treat them with antibiotics, and it didn't make a significant difference in the mortality, didn't make a difference in the ICU admission rate after 48 hours or length of stay. So it kind of definitively said, no, we don't think so. We don't think treating these patients with pneumonia symptoms with a positive viral assay makes a difference. So disagreed, and we've got kind of uh two differing societies now, and now it kind of leaves us in the middle of uh with being internal medicine primary for these patients, deciding on what to do. What was your thoughts?

SPEAKER_01 18:41

Yeah, this was this was fun, and and like I said at the top, like we're we're addressing a controversy here, and um, it's a little bit nerdy for this to be like this is drama, but it's about as high drama as this gets. It's about as high drama as uh evidence for inpatient medicine gets. So boom, we're excited today. Um, but it it this was another thing that I heard mention of um at the SHM conference that there was uh updates in the guidelines talk, and they had this little graph that was like a bridge, and it was the IDSA and the thoracic association agreeing on guidelines and putting out guidelines together, and then it's like all of a sudden schism and things are breaking and they're going different ways. So it's dramatic. And I think this is an impressive feather in the cap of the IDSA to say our recommendation that we do not routinely recommend antibiotics for folks that get admitted for pneumonia and have a positive viral panel. I think this is this is backing them up pretty well. The question I have on it though is how much is this changing our routine and our day-to-day practice? What are your thoughts? Before we read this article, before we looked at this drama with the guidelines, what would have been your go-to? You've got someone who fits in the inclusion criteria of this study. So you've got someone you admit, they are hypoxic. They said less than 95 on room air. So maybe they're on a little bit of oxygen, maybe they're on a lot of oxygen, uh, maybe they're on no oxygen and just sort of flirting with that less than 95. They're tachypnic. And the inclusion criteria was chest imaging was ordered, but they didn't do any assessment of that testing. Um, so you get that patient and you're admitting them to your surface. And I mean, I'll pretty much guarantee you they're they're gonna that's part of why we do zero to two days, I'm sure. Is they've gotten a dose of ceftriaxin and a zipin or something in the ED. But if you're admitting that patient going forward, are you continuing them on antibiotics or are you were you not before before reading this?

SPEAKER_00 20:47

There was a patient I had pretty recently, um, 30-year-old, relatively healthy, you know, no other comorbidities, had a bad viral infection, diagnosed it right away, and he was a hyp, you know, tachycardic in 120s, hypoxic, needing a few liters, and decided not to continue antibiotics from the ED. And to try and explain that to patients as well as family when they look that sick, you know, goes back to the there's no such thing as a benign medication. Everything has adverse effects. So before I was not doing it, um, was not treating, you know, these uh patients with a positive viral culture, unless I something in their story made me suspect superimposed bacterial infection, so I would not be treating it. This just gives me more ammo to really say and and more comfortability to say it doesn't matter.

SPEAKER_01 21:43

I was practicing similar to you that if I didn't have a reason to and I thought the virus was the reason for their pneumonia, I wasn't routinely giving antibiotics. So going forward, who who do you think's which which path are you going down? Are you team thoracic society or are you team ID society.

SPEAKER_00 22:01

100% team ID all the way. And I'll continue to feel support with this article and continue to not give these guys antibiotics. They have the positive viral assay.

SPEAKER_01 22:13

100%. Two for two, we're team IDSA. Inpatient Update officially disagrees with the recommendation that you give all patients you admit with a positive viral panel in respiratory symptoms, antibiotics. Before we had this study, I would have said, these experts say this, this, these experts say this. It's hard to say. I don't know. Maybe I'm going to go the more conservative route and give everyone antibiotics. So I really do think I'm glad they did the study, and it totally puts me in the bucket of, to be clear, the guideline of not routinely recommending. And now, again, similar to our other study, this trial has its limitations. This is not a randomized controlled trial. It's retrospective. And so similarly, I think there's some degree that the patients could have self-selected that sicker patients are going to end up more likely to get the antibiotics. So it just makes things a little more complicated there. Honestly, any of these people, if you end up in the ICU, it's hard to imagine you're not getting antibiotics and getting that conservative treatment. Because similarly, not only did they not they didn't do better with antibiotics, they also didn't do worse with antibiotics. They didn't. This was all no statistically significant changes, including like rates of C. diff and all of that. And so, yes, there are complications with antibiotics, but we're not seeing that those patients do worse off. I do want to be a good steward of antibiotics, but honestly, in my data practice, what I care more is what's going to be best for my patient. So if they don't need antibiotics, I won't give it to them. But if they seem like they need it, I'll give it to them. But definitely not routinely giving everyone who has comes in flu, COVID, RSV, antibiotics if I don't think they have a bacterial pneumonia. I wasn't doing that before.

SPEAKER_00 23:58

One thing I really liked about this study, um, and we keep saying, oh, it's retrospective, but they didn't pool any any punches with who they selected. They over 30% of them on the initial selection went to the ICU. Um and then on the continued, you know, after um being excluded for procalcitonin elevation and um and short stays, these guys were still, you know, over 20% of them still went to the ICU, no matter if they got short dose, short um, short dose of antibiotics or longer dose. You know, these guys are pretty sick. And I think this kind of speaks to we're learning more about viruses and how sick a person can be with just the virus. And I think that's partly because of COVID times, and then partly because we're we're seeing almost any virus can do this. There's some in the study they say they note um adenovirus and like rhinovirus. Um, over 90% of them got antibiotics because we're just we keep thinking, oh, you know, I I don't think this virus can cause this. But now we're showing in this study, like, no, these viruses can make you pretty sick. And giving them antibiotics just because it's a quote weaker virus may not make a lot of sense. So um it's it's an interesting um division that we have now.

SPEAKER_01 25:24

I'm sure the IDSA would have loved to see that the patients without antibiotics actually do it better from at least either like a length of because I expected to see like I was looking at like the C diff numbers and the length of stay numbers and thought, like, if we're not giving them antibiotics and tying them to that, are they getting out of the hospital quicker? Yeah, none of that. All of that, yeah. It was it was it was 50-50. Is this study actively changing your your practice in any way going forward?

SPEAKER_00 25:51

It's actively changing and continuing to do what I'm doing and not giving these guys antibiotics.

SPEAKER_01 25:58

Sometimes no change is a change.

SPEAKER_00 26:01

But it makes me more confident when I can go into the room and tell patients and loved ones, no, we we are okay to hold off antibiotics for now. But that's the reason you're in the hospital to continue to monitor clinically. We we can't we don't have a crystal ball to know if there's superimposed bacterial infection, but that's why you're here. If you don't get better, it's no harm to continue to to monitor you and then change, change based on how you do clinically.

SPEAKER_01 26:30

Similarly to our first study, this is this is kind of what I was doing, anyways. If I thought the virus was the cause, I wasn't giving antibiotics, but it's probably moving me on the margin. So like I'm gonna be that rhino, that adenovirus. In more patients, I'm gonna be saying it's gonna just that move me that little bit that I'm that much more likely. If I've got a patient coming in and I can hang this on a virus, then I'll do it. And then if they get worse or give me any reason, then low threshold to start antibiotics, I'm probably not gonna make anything worse if I do, if I think they really need it, but it will move me that little bit going forward. Recapping when it comes to urgent one-time hypertension, acute hypertension in the hospital setting, the data supports you not treating that. In fact, outcomes are worse in the patients that it gets treated. This is something we generally do for no reason, but we're really looking for that randomized control tile that tells us absolutely it's the wrong thing to do. If you're giving something, you should be gentle in what you're giving them because you're going to cause more harm by dropping a patient quickly than you are by letting them stay at a hypertensive number over the course of hours in the hospital.

SPEAKER_00 27:44

That's right.

SPEAKER_01 27:45

And when it comes to patients that are admitted with hypoxia, evidence of pneumonia, who have a positive virus, you do not need to do antibiotics in those patients unless you think they actually have a bacterial component. Inpatient update, Dr. Turner, Dr. White, our team IDSA, and we do not think those patients admitted with viral pneumonia routinely need antibiotics going forward. Thank you so much. It's it's been a joy, it's been a pleasure, and I'd love to have you on the show again sometime.

SPEAKER_00 28:21

I appreciate it. More controversial articles are always fun.

SPEAKER_01 28:25

Right. And to our audience, um, thank you so much for joining us. And if you find this useful, please send it and share it with your colleagues or classmates. And if you've got any new evidence you think we should be talking about, and or you are a provider, a specialist, a nurse, a pharmacist, or anyone with value-added insight into the management of hospitalized patients, please reach out to me. You can reach out to me directly or contact Inpatient Update on social email social media or email me at podcast at inpatientupdate.com. Thank you so much for being with me, Dr. White, and thank you to the audience. This has been Inpatient Update.