SPEAKER_00 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, we're doing something a little different. This is our first semi-annual takeaways episode, the creme de la creme of inpatient updates so far. Over the first 10 full episodes, we've covered more than 25 recent articles, all through the lens of one question. What should you actually change on rounds tomorrow? The goal here is to step back, connect the dots, and distill the biggest practice-changing themes from everything that we've covered on the show so far. If you've been listening from the beginning, think of this as a little time-spaced repetition for the articles most likely to change what you do. If you're new to this show, this is probably the fastest way to understand what inpatient update is all about. Practice changing evidence for the working hospitalists delivered efficiently to make it easy on you without getting lost in all of the statistical weeds. I'm going to tap count down my five takeaways from number five to number one, and for each one, I'll feature a short clip from the original episode. Let's get into it. Number five, pneumonia care should be more deliberate. This theme showed up in a few ways. So in episode eight with Dr. Jaffey, we talked about using CRP to identify which patients with community acquired pneumonia may actually benefit from steroids. In episode seven with Dr. Austin White, we talked about how a positive viral panel should make us pause before we reflexively start giving antibiotics to these patients. But the biggie was episode nine with Dr. Ernest Murray, where we discussed the annual study suggesting that for selected improving patients admitted for CAP, three days of antibiotics may be enough. The takeaway is not do less for every pneumonia patient. It's that pneumonia care should not reflexively be five plus days. Three days is often enough. Here's my conversation with Dr. Murray. So, Dr. Murray, how often do you treat a patient for pneumonia?

SPEAKER_02 2:54

Like all the time. It's like our favorite. It's pneumonia and urinary tract infections. Hospitalists love diagnosing those two things. If not, we're gonna find it. You know, if anyone looks weird, we're doing chest x-rays. The chest x-rays, we overread them, we under read them. We sometimes just perfectly read them. But yeah, we love diagnosing cap and cap hap, all that stuff.

SPEAKER_00 3:14

Um cap happen bap. So you want you want to tell us about the article we have here today, and then we can get more into our thoughts and how this might change our practice?

SPEAKER_02 3:23

You know, very interesting article that was published in the Annals of Internal Medicine that looked at uh at community acquired pneumonia in a group of people in Michigan. And so they looked in this large uh database in Michigan that's promoted between 2017 and 2024. And um, they were focusing on trying to figure out whether or not there was any difference between treating people for five days or treating people for three days for community-quire pneumonia. And so their outcomes were 30-day all-cause mortality or 30-day readmission or urgent care visits, and and then specifically the antibiotic associated uh C diff. So they compared the control versus the intervention groups, where intervention groups were three to four days versus control was five plus days. And they found that ultimately that there was no significant difference between mortality, urgent visits, C diff infection, or readmissions.

SPEAKER_00 4:29

Yeah, I kind of see this as this is reassuring. It's not necessarily groundbreaking, it's not necessarily major change, but it is a little bit of a comfort blanket that what I was kind of tending to start to want to do, and we can get more into the guidelines and why we're kind of tending to want to do that, and lowering my duration of my treatment for community acquired pneumonia and people who are really stable. This is giving me a little bit of reassurance that at least the data doesn't show that it's worse, given the limitations of this study.

SPEAKER_02 5:05

Yeah, I mean, I I think the the interesting thing is that, you know, we're trying to support that these guys were trying to support the idea that using antibiotics less is better. In 2019, these exact same guys came out with a study that showed that using antibiotics longer increased antibiotic associated side effects by 5% for every day that you do it. So they these guys were gun-ho about doing that. For for for good bit for you know, for good cause too. These are the crown jewels of medicine, you know, uh, and we are afraid to hurt people, you know. But the they they supported that with this, and I think that with the 2000 and 2025 guidelines, I think it it's opening the door for us to use antibiotics less. Looking closely at those guidelines, you know, in three days, can you really eradicate an infection in three days? And I think the answer is you're not, actually. You're not eradicating the infection, but do you need to?

SPEAKER_00 5:56

There's so much of a less is more push, and so much of decreasing duration being a priority. And usually the data backs it up that we get at worst, the data we have here that's at least that it's not worse. But we're seeing that more and more, and that is the push. Um but obviously it's within the caveat of you know, you look at your whole patient and you're treating your whole patient. You're not and I think that's what this does for us is I think before, like you say we don't want to hurt patients, we kind of do a more is more and reflexively say, all right, everyone gets at least five days, or some people are everyone gets seven days. But this is giving us sort of the comfort to be, okay, let's just take this patient by patient. Let's look at the patient, let's not look at the diagnosis code and just say that's gonna determine what their treatment is. A equals B, we're gonna look at the chase patient in more context of them, and maybe we're gonna get rid of 90% of our patients. We are gonna do five to seven days. But 10% of our patients, if they look good, then maybe we stop. Then these updated 2025 guidelines, for anyone who hasn't seen that yet, had said that so basically the minimum is three days and the recommendation less than five days if they're really stable. Basically, what we're seeing in this in this study, and despite some of the trauma about those guidelines, the IDSA backed up and agreed on on that part. So I think mostly agreed. Yes, yeah, mostly agreed. Yeah, but any other any other specific thoughts on those guidelines you think the people need to know?

SPEAKER_02 7:31

This is a good question about what are the kind of patients that we're talking about here, other than having requiring hemodynamic stability, other than requiring that you're your ephibrile, other than you, you know, you're off of the oxygen. The the other thing is like who are the what's the patient population? And our patient population are the you know, multi-organ system failure, solid lung and transplant, you know, or solid organ transplant, you know, people that are on stereotypes, those are the patients that were all excluded, you know. So like people that are immune-suppress, you know, they probably, you know, they probably bought themselves a few more days of antibiotics, even if they are clinically improving fast. But uh, but a majority, you know, the the question should be asked for those relatively stable patients who are not, who are not in that kind of higher risk category.

SPEAKER_00 8:12

Agreed. Sort of my takeaway. Taking the 2025 guidelines and like you're saying, the the data on VAP and this data. Basically, my takeaway is that my mental minimum needs to be three days, not five to seven days. But I'm treating my patient in front of me and they have to be very stable, not complex for me to be comfortable doing that that minimum, at least based on current evidence. Number four, please give your patient the flu shot before discharge. This one comes from episode six with Dr. Emily Reims, where we talked about the Panda 2 trial, influenza vaccination in patients admitted with acute heart failure. And the big takeaway is almost too simple. If it's flu season and your hospitalized heart failure patient has not gotten the flu shot, that admission is an opportunity. A one-time intervention before discharge that reduces readmission and mortality, that should be a priority for providers. Here's my conversation with Dr. Reims. So, Dr. Reims, um how often do you have someone on your service who has congestive heart failure?

SPEAKER_05 9:37

Every day.

SPEAKER_00 9:38

Every day. What if I told you, at least in folks with moderate to severe, that there was one single medicine you could give people that would reduce both their mortality and their readmission over the year with a number needed to treat of 17. What would you think that medicine was?

SPEAKER_04 9:55

I would think that that would be. I would think that might be a beta blocker. Yeah, right? Entresto.

SPEAKER_00 10:01

Ooh, entresto. The cardiologist loved entresto.

SPEAKER_06 10:04

Yeah.

SPEAKER_00 10:05

Um so actually, it's a one-time medicine. You've taken it this year, I've taken it this year.

SPEAKER_06 10:13

Or else I can't go to work. Yes. Exactly. So the flu shot. Shocking. Yeah.

SPEAKER_00 10:18

Just a flu shot and 17 patients, which takes like what? You know, two weeks on service. Two weeks on service. Maybe. And you've saved a life andor readmission within the next year. And for adverse events they left at it was a number needed to treat a 15. I love a number needed to treat.

SPEAKER_05 10:34

I know, I do too. And there's something really nice about a one and done flu shot. And you really are going to deal with CHF every single day.

SPEAKER_00 10:45

Part of what was great about the conference is it was just a reminder of stuff. Like to give a flu shot. Like, duh. Of course I should be giving everyone a flu shot in flu season. But the fact that I have this 100% is going to be on my radar going forward. I met someone with heart failure. It's a season when we have a flu shot. I will be giving them a flu shot. I will be giving anyone who will let me a flu shot who gets admitted to the hospital during the time that there's flu shot.

SPEAKER_06 11:06

You're going to become a menace just walking around with a flu shot. Save lives. You are going to save lives. And I think you should quote this study to all of your patients who refuse flu shots. I'm just trying to save your life.

SPEAKER_00 11:18

I'm going to uh yell it at whoever tells me we're out of the flu shot.

SPEAKER_06 11:22

Oh, well, that's actually more likely. We do tend to run out. There's always a shortage.

SPEAKER_00 11:30

Number three. With blood thinners, sometimes less is more. This theme came up again and again. First in the solo pilot episodes where we talked about reduced dose of pixaban for extended treatment for cancer-associated veno-thromboembolism. Came up again in episode eight with Dr. Jaffey, where we talked about bleeding risk differences between a pixeban and river roxpan. And episode 10 with Dr. Farley, where we decided heparin for DVT prophylaxis usually is more harm than good. But my big one was episode three with Dr. Andres Ospina, where we discussed the aquatic trial. For patients with stable coronary artery disease who you're starting on oral anticoagulation, stop the aspirin. Your patient is more likely to stay alive without it. Here's that conversation with Dr. Ospina. So, Dr. Ospina, I'm sure you've a lot of times had these patients like I have who have a history of coronary artery disease. They're on aspirin. And then I just recently had a patient who was maybe a 70-ish year old woman, came in for surgery, was on aspirin, and then had some post-op AFib, and we started anticoagulation. And previously, honestly, I just start the anticoagulation and don't even think twice. Well, I think twice, but had done little pause of what should I be doing with the aspirin. But there was a recent study released in just October of last year that addressed just that. So this was the aquatic trial, an article titled Aspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation. And it was in the New England Journal of Medicine in October of 2025. So this was a multi-center, double-blind, randomized placebo control trial that had 872 patients randomized to either get anticoagulation alone or anticoagulation plus aspirin. And these were patients that had a history of coronary artery disease with a cabbage or PCI that was more than six months ago, and then uh had a reason to start anticoagulation. And so what this study looked at was a composite outcome, sort of your kind of a typical composite outcome, cardiovascular death, heart attack, stroke, need for coronary reasculation. They included acute limb ischemia. So they compare, again, comparing aspirin to aspirin plus anticoagulation in this patient group that has a history of coronary artery disease on aspirin for secondary prevention. Um, and they found that the hazard ratio was 1.53 for increase in the composite outcome and folks that got both the anticoagulation and the aspirin together. So that was about 17% of those folks getting both compared to 12% getting um anticoagulation alone, obviously with a placebo saying it was placebo-controlled. They looked at uh a few other um outcomes as well, as secondary analysis. They looked at death from any cause was also higher in the aspirin plus anticoagulation group. And then they looked at major bleeding, and that was 10% in the aspirin plus anticoagulation group compared to 3.4% in the anticoagulation alone group. And that had an adjusted hazard ratio of 3.35 that was statistically significant, significant, obviously, from those numbers, pretty significant. So all that is to say, the headline is obviously these patients that have, you know, had a PCI one, two, three, whatever more than six months ago, who now have nuanced AFib or a DVT or whatever and need anticoagulation, they do better if you stop the aspirin. So for my lady, I kind of referenced at the top. I actually um, I said recently taking care of her, and this was recent enough that I had read this article. And specifically for her, I talked with the team. I was um co-managing the patient. I talked with the team, I said, hey, let's stop the aspirin and her and do eloquence alone for her for her AFib plus remote history of coronary artery disease. So what do you think, Dr. Ospina? Something you're gonna use in your practice, something you're not gonna use? Any thoughts?

SPEAKER_03 16:13

No, I mean, certainly, truth be told, before you sent me this article, um, I wasn't aware of this particular trial. And then even full disclosure, my wife is a cardiology fellow, and so she immediately knew about what I was talking about, or you know, referring to this article. But I think what was interesting to me, and just much like you pointed out, like this article specifically kind of focused on on high-risk patients, really with prior stents. And I think a large proportion of these patients greater than 70 or somewhere around there had prior MIs. And so I think very applicable. I think like just like you said, I think perioperatively, whether we're co-management or or consults, and then patients just really coming in for any reason, whether it's a new a new a new embolus of some co sort or a new, you know, thromboembolic event that do happen to be on aspirin for for coronary disease. I think very, very much so pertinent. And and I think one of the pitfalls, if I'm being honest about it, is when I've encountered these situations in the past is is more better, is keeping them on aspirin better because they are high risk. And and I've I've done probably have done that into the point where, okay, we're starting in equagulation. Well, I'll leave them on aspirin and have them follow up with a cardiologist or whatever the case may be. And I feel like that this is enough evidence, particularly even in such a high-risk population, which we oftentimes see to tell me that not really that aspirin needs to be peeled off. And so certainly something that makes me change my perspective on it, and certainly something that's applicable probably day to day, depending on kind of who we're seeing.

SPEAKER_00 17:42

Yeah, to your point, patients will ask this a lot when I start them on an anticoagulation in this setting, and they're like, oh no, already taking aspirin for anticoagulation, or probably more often if they're on daft and they're on uh plavex or something else. And I'll be standing there telling them about like antiplatelet being different than anticoagulation, and you still want that antiplatelet effect and yada yada yada. And this is telling us that, you know, that's not true. And not that it's not true from a pathophys standpoint, but looking at the study, the fact that they looked at major bleeding as a subgroup, and that's where you see such a big difference. It's pretty clear to me from these numbers and just logically that the difference was that the aspirin plus anticoagulation people bled more, and therefore they had more MI and cardiovascular death and everything else because they were bleeding. It seems obviously that was the major driver here, which makes sense. Number two, we are entering an era of shorter antibiotic durations. We talked about this in episode five with Nicholas Lindy, PA, where we talked about de-escalating antibiotics and sepsis. We also talked about it in episode four with Dr. Kevin Baker, where we discussed Dalbivansin raising the possibility of getting select patients with staph aureus bacteremia out of the hospital without requiring weeks of traditional IV antibiotics. But my central article here was the balance trial from episode three in my discussion with Dr. Andre Sespina. For uncomplicated bloodstream infections, not staph aureus, not endocarditis, not osteomyelitis, but uncomplicated. Seven days of treatment was non-inferior to 14. The takeaway isn't just short antibiotics for everyone. It's that 14 days should no longer be our reflex for bacteremia, and seven days is often enough. Here's that conversation with Dr. Ospino.

SPEAKER_03 19:49

So I guess I'll go ahead and jump right into it as you kind of alluded earlier that this article is now or this trial now referred to as the balance trial. I think this came out kind of November of 2024, if I'm not wrong. But this was a trial uh published in the New England Journal of Medicine looking at antibiotic treatment, particularly in patients with bloodstream infections, and really a head-to-head kind of somewhat comparison of seven-day treatment versus 14 days. Um it was a multi-center randomized non-inferiority trial. It was based across three different countries: Canada, Australia, and New Zealand. It looked at um just over 3,600 hospitalized patients, meaning adults with bloodstream infections. There was a little bit of a stringent um exclusion criteria, particularly um as it relates to kind of you know certain severe or what we consider severe um bugs or microbes. Staph aureus was excluded, staph lug was also excluded, um, fungemia was excluded, and other rare bacteremias that required kind of prolonged therapy. Um, patients that had prosthetic valves, endographs, or any sort of syndrome that we know required prolonged IV antibiotic therapy, including endocarditis, osteomyitis, and that nature were excluded. And lastly, severely immunocompromised patients. Really, the the comparison of the intervention was the seven-day total of antibiotic therapy group as compared to the control, which was the 14-day total group. Um, and they were looking at really a primary outcome of death at any cause or of any cause at 90 days after diagnosis. Um, and interestingly enough, what the result suggests is that at seven days, the uh looking at the primary outcome, again, death and any cause, that was about 14.5% of patients compared to 16.1% um in the control 14 day group. So, really a net absolute difference, negative 1.6%. And even so, secondary outcomes looking at hospital mortality, relapse of bacteremia, really no significant difference. Length of stay were actually fairly similar. And of course, in the seven day strategy, antibiotic free days at 28 days after diagnosis was So, really, the bottom line is in hospitalized patients or hospitalized adults with uncomplicated bloodstream infections, including those that have been in the ICU, seven days of antibiotic treatment was non-inferior to 14 days with respect to death by the 90-day mark after the diagnosis. Um, but anyway, for me, I think again, when you when you extrapolate it and think about how applicable it is for a day-to-day hospitalist, I think I focus on I think one, yes, it is very applicable. I think we see a lot of ICU transfers, people coming in and out of the ICU. I think infection and bacteria is exceedingly common in the hospital. I think takeaways for me is kind of you know being mindful of what this uncomplicated bacteremia is or how they how you view it, right? And really it's just kind of based on the exclusion criteria, making sure that the host has no severe immunocompromise states, really targeting on the bug. Of course, no syndromes, no endocarditis of the sort. But but with source control and with appropriate antibiotic therapy, I think that that it's very, very insightful and I think will help me in the long run. I think it's from what I'm gathering here, and I would love to get your thoughts on this, most beneficial to me as a day-to-day guy when it comes to the urinary and intraabdominal infections. I think those by far are common. People that are patients that come in with pyline nephritis, bacteremia, E. coli, right? There's a kind of a common scenario that I see where I'm giving 10 to 14 sometimes, and it's you know, there's evidence here now.

SPEAKER_00 23:37

I agree. Yeah, huge, right? I seven days being just as good as 14 days, massive difference. And really, I think the biggest thing is gonna be who goes home with a pick and who do we finish in the hospital. Number one, stop treating asymptomatic inpatient blood pressures. This comes from episode seven with Dr. Austin White, where we discuss the jam internal medicine VA study on PRN blood pressure medications in hospitalized patients. This is my number one because it's so common, so reflexive, and might actually be harming your patients. When the patient has no symptoms, no end organ damage, the first question should not be what PRN should I give? It should be why is the number high? Does this patient actually need acute treatment? Or might my acute treatment actually harm this patient instead? Here's that conversation with Dr. White. 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? No. Anything in that range sound like something you've ever had to deal with?

SPEAKER_01 25:06

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

SPEAKER_00 25:11

And we'll talk more about this. But when that first digit gets to be a two, it's like I mean, for me, I mean, everything changes a little bit. Um, and how comfortable I feel and how strong I feel in my um in my dogma. Um but what do you do? What do you do when you get that page? What's what's your go-to response? What's your go-to reaction?

SPEAKER_01 25:29

Yeah. 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.

SPEAKER_00 25:39

But do you have a limit?

SPEAKER_01 25:42

Um when I start getting more invested or interested in the number, it's definitely got to be like over 180. And then I'm like, okay, maybe I'll I'll consider being more aggressive and treating it. Um but at at some points at night, it does feel like you're just treating the number and you're treating the um the myself as well as staff, uh, as opposed to really treating the patient sometimes, if if you're for some of the uh the numbers that I get paged about. Yeah, usually I'm not kind of treating or or investigating more aggressively if it's if it's under 180, but my number would be about 180. And then I start looking into it more.

SPEAKER_00 26:23

That's um and so this was in published in Jamma Internal Medicine. It was published in 2025. It was entitled As Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals. 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 AKIs, 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, um, heart attack and dying, I'm gonna be particularly interested. Um, and was also statistically significant, more in the group that got treated with PRs and PRNs with a hazard ratio of uh one point. 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. I'm in the primary out. Um and so that's sort of the big picture of this. And so I found it helpful to see numbers that state if you treat patients or the patients that are being treated with PRN, antihypertensive, one-time antihypertensives for an elevated blood pressure, we're actually seeing worse outcomes, on which I think it's nice to have this data kind of backing that up. But do you have any initial thoughts or impressions on this?

SPEAKER_01 28:39

It 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_00 29:04

Definitely. I like I said, I just it's something I've been trying to do and been aware of. And it's nice to have a study that it's one of the another one of those times where it's almost like a comfort blanket study. No. That it's like, it's okay. You're not making things worse by not doing it. And I'd say the this kind of similar to the study backing me up, making me feel more comfortable, that I'm not like it does, it is reassuring, even with its limitations. It is reassuring that you're not causing harm by holding the line and not treating asymptomatic hypertension. 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, for seeing your 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 were new guidelines from 2024, and that's basically do not treat asymptomatic elevated blood pressure acutely, specifically mentioning treatment should generally be the exception and not the rule, which is which is how I tried to do practice. But like I said, when it gets the number gets to where it's starting with the two, it's hard for me to, it's hard for me not to be say that's always the exception. Just like your patient, if you've got a patient who's otherwise healthy, you know, it's a guy and his he's he's whatever 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. Um, 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. And that's uh the big takeaway is when you get that page, the first thing should be, are they symptomatic? And the second should be, let's look, are there any underlying causes? And if there are, let's treat that.

SPEAKER_01 31:00

That's right.

SPEAKER_00 31:01

Um, go ahead. All right. So what do you think? Is this gonna change? Is this discussion and or this trial gonna change your practice going forward? And if so, how?

SPEAKER_01 31:11

I would like to think it would. Hope that I would continue to hold the line at night. 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 eliminated all other sources of potential uh hypertension, such as like stress and surgery, things like this, pain, and and go from there. So tentatively and hopefully, yes, it'll change my practice for the better.

SPEAKER_00 31:51

So that's it. Those were my top five evidence-based practice-changing takeaways from the first six months of inpatient update. For select patients with community-acquired pneumonia who are clinically improving. I'm no longer reflexively thinking five days is the floor, three days of treatment is often enough. For patients admitted with heart failure during flu season, I'm on a mission to give them a flu shot before they discharge. Along with all my patients for that matter, this will save lives. For patients with stable coronary artery disease who now need oral anticoagulation, I'm stopping the aspirin. This one is so important and it's saving lives too. For uncomplicated bloodstream infections with source control, I'm cutting my IV antibiotic duration to only seven days in most patients. And for asymptomatic inpatient hypertension, I'm not just treating the number. I'm checking for symptoms, looking for the cause, and avoiding PRN blood pressure meds. And that's it. That's our show. If this episode was helpful, send it to one person who takes care of hospitalized patients. And if you want the article links and key takeaways from each episode, join the email list at subscribe dot impatient update dot com. Thanks for listening. This has been Impatient Update.