Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
1. ACP Best Practice Advice: Shorter course of antibiotics may be appropriate for some common infections
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The American College of Physicians (ACP) has issued Best Practice Advice suggesting that a shorter course of antibiotics may be appropriate for some common bacterial infections, as overuse, resistance, and long and unnecessary use remain major health care issues. The paper addresses best practices for prescribing appropriate and short-duration antibiotics for patients presenting with these infections. ACP’s Best Practice Advice is published in Annals of Internal Medicine.
Authored by ACP’s Scientific Medical Policy Committee, ACP’s Best Practice Advice defines appropriate antibiotic use as prescribing the right antibiotic at the right dose for the right duration for a specific infection. The paper was developed by conducting a narrative literature review of published clinical guidelines, systematic reviews, and individual studies that addressed uncomplicated bronchitis with COPD exacerbations, community-acquired pneumonia, urinary tract infections, and cellulitis. When clinically safe and supported by evidence, shortening antibiotic duration decreases overall antibiotic exposure, reducing the risk for resistant organisms to develop, as well as lowering a patient’s risk for adverse side effects. Specifically, ACP recommends the following:
- COPD Exacerbation and Acute Uncomplicated Bronchitis: Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea and/or increased sputum volume).
- Community Acquired Pneumonia: Clinicians should prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation.
- Uncomplicated Urinary Tract Infection: In women with uncomplicated bacterial cystitis, clinicians should prescribe short course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short course therapy either with fluoroquinolones (5-7 days) or trimethoprim-sulfamethoxazole (14 days) based on antibiotic susceptibility.
- Cellulitis: In patients with nonpurulent cellulitis, clinicians should use a 5-6 day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.
In the United States, at least 30% of antibiotic use was considered unnecessary and often continued too long. The ACP and the Centers for Disease Control and Prevention (CDC) have recognized antibiotic-resistant infections as a national threat.
2. Personalized patient navigation service reduces readmissions among hospitalized patients with comorbid substance use disorder
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A personalized patient navigation service reduced hospital readmissions and emergency department (ER) visits for patients with comorbid substance use disorder. Findings from a randomized trial comparing Navigation Services to Avoid Rehospitalization (NavSTAR) versus usual treatment are published in Annals of Internal Medicine.
Hospitalized patients with comorbid substance use disorders are considered a vulnerable patient population at high risk for poor outcomes and very frequent and fragmented hospital utilization. A coordinated hospital discharge approach that addresses medical needs, addiction, self-care, and basic living requirements is needed to reduce health care utilization and improve health for these patients.
Researchers from Friends Research Institute, Baltimore, MD, randomly assigned 400 hospitalized patients with comorbid substance use disorders involving opioids, cocaine, or alcohol to NavSTAR or usual care upon discharge to determine whether patient navigation services would reduce hospital readmissions. All participants were seen by an experienced addiction consultation service while in the hospital and 92% met criteria for severe substance use disorder, while 43% were homeless. In the NavSTAR group, participants received patient navigation services after discharge for up to 3 months. Data on inpatient readmissions (primary outcome) and ER visits for 12 months were obtained for all participants via the regional health information exchange. Entry into substance use disorder treatment, substance use, and related outcomes were also assessed at 3-, 6-, and 12-month follow-up.
The researchers found that participants had high levels of acute care use: 69% had an inpatient readmission and 79% visited the ER over the 12-month observation period, many of them with multiple readmissions/ER visits. Participants in the intervention group had reduced hospital readmissions and ER visits compared with usual care over the 12-month study period. NavSTAR reduced rapid readmissions, meaning that it cut 30-day readmission by about half. Participants in the NavSTAR group also had increased entry into substance use treatment in the community.
According to the researchers, hospitals should devote resources to addressing comorbid substance use disorders, which can greatly affect health and prognosis.
Also in this issue:
Knee Osteoarthritis – Does the Type of Shoe Matter?
Robert M. Centor, MD,
Annals On Call
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