Roxana Naderi, MD

Clinical question: Does testing procalcitonin for lower respiratory tract infections (LRTIs) decrease total antibiotic days without a resultant increase in adverse events?

Background: LRTIs are frequently overtreated with antibiotics. Procalcitonin may indicate bacterial infection and promote antibacterial stewardship. Studies to evaluate how testing procalcitonin affects antibiotic use for suspected lower respiratory tract infections are limited.

Study design: Randomized 1:1 intention-to-treat, multicenter trial.

Setting: 14 U.S. urban academic hospitals.

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Synopsis: 1,656 patients across 14 U.S. hospitals were randomized to initial procalcitonin results available prior to clinical decision making versus usual care. All providers were given Food and Drug Administration–approved guidelines to interpret procalcitonin results. In the procalcitonin group, procalcitonin levels were followed serially. Within 30 days of the initial encounter, total antibiotic days did not differ significantly between the two groups. Procalcitonin use did not significantly affect adverse outcomes including organ system failure, death, ICU admission, hospital readmission, or ED visits. A total of 20% of antibiotic prescriptions were written prior to the procalcitonin result. Providers who did not adhere to guidelines either cited a diagnosis of chronic obstructive pulmonary disease or discounted the value of procalcitonin and presumptively diagnosed bacterial infection (40% of cases).

Bottom line: Procalcitonin testing did not change provider practice patterns for antibiotic prescriptions for LRTIs.

Citation: Huang DT et al. Procalcitonin-guided use of antibiotics for lower respiratory tract infection. N Engl J Med. 2018 Jul 19;379(3):236-49.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.

Clinical question: Does testing procalcitonin for lower respiratory tract infections (LRTIs) decrease total antibiotic days without a resultant increase in adverse events?

Background: LRTIs are frequently overtreated with antibiotics. Procalcitonin may indicate bacterial infection and promote antibacterial stewardship. Studies to evaluate how testing procalcitonin affects antibiotic use for suspected lower respiratory tract infections are limited.

Study design: Randomized 1:1 intention-to-treat, multicenter trial.

Setting: 14 U.S. urban academic hospitals.

Image

Synopsis: 1,656 patients across 14 U.S. hospitals were randomized to initial procalcitonin results available prior to clinical decision making versus usual care. All providers were given Food and Drug Administration–approved guidelines to interpret procalcitonin results. In the procalcitonin group, procalcitonin levels were followed serially. Within 30 days of the initial encounter, total antibiotic days did not differ significantly between the two groups. Procalcitonin use did not significantly affect adverse outcomes including organ system failure, death, ICU admission, hospital readmission, or ED visits. A total of 20% of antibiotic prescriptions were written prior to the procalcitonin result. Providers who did not adhere to guidelines either cited a diagnosis of chronic obstructive pulmonary disease or discounted the value of procalcitonin and presumptively diagnosed bacterial infection (40% of cases).

Bottom line: Procalcitonin testing did not change provider practice patterns for antibiotic prescriptions for LRTIs.

Citation: Huang DT et al. Procalcitonin-guided use of antibiotics for lower respiratory tract infection. N Engl J Med. 2018 Jul 19;379(3):236-49.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.

Clinical question: Does testing procalcitonin for lower respiratory tract infections (LRTIs) decrease total antibiotic days without a resultant increase in adverse events?

Background: LRTIs are frequently overtreated with antibiotics. Procalcitonin may indicate bacterial infection and promote antibacterial stewardship. Studies to evaluate how testing procalcitonin affects antibiotic use for suspected lower respiratory tract infections are limited.

Study design: Randomized 1:1 intention-to-treat, multicenter trial.

Setting: 14 U.S. urban academic hospitals.

Image

Synopsis: 1,656 patients across 14 U.S. hospitals were randomized to initial procalcitonin results available prior to clinical decision making versus usual care. All providers were given Food and Drug Administration–approved guidelines to interpret procalcitonin results. In the procalcitonin group, procalcitonin levels were followed serially. Within 30 days of the initial encounter, total antibiotic days did not differ significantly between the two groups. Procalcitonin use did not significantly affect adverse outcomes including organ system failure, death, ICU admission, hospital readmission, or ED visits. A total of 20% of antibiotic prescriptions were written prior to the procalcitonin result. Providers who did not adhere to guidelines either cited a diagnosis of chronic obstructive pulmonary disease or discounted the value of procalcitonin and presumptively diagnosed bacterial infection (40% of cases).

Bottom line: Procalcitonin testing did not change provider practice patterns for antibiotic prescriptions for LRTIs.

Citation: Huang DT et al. Procalcitonin-guided use of antibiotics for lower respiratory tract infection. N Engl J Med. 2018 Jul 19;379(3):236-49.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.

Clinical question: For patients who develop a gastrointestinal bleed (GIB) while using direct oral anticoagulant (DOAC) therapy for atrial fibrillation (AF), does the risk of venous thromboembolism (VTE) or recurrent GIB increase after DOAC resumption?

Background: DOACs are increasingly used for stroke prophylaxis in nonvalvular AF and can increase the risk of GIB by 30% compared to warfarin. Although warfarin can be safely resumed within 14 days of GIB cessation, outcomes related to resuming DOAC therapy after hospitalization for GIB are lacking.

Study design: Retrospective analysis of claims data.

Setting: Patients with AF on DOAC therapy admitted for acute GIB in Michigan.

Synopsis: 1,338 adults, median age 79 years, on a DOAC for AF were hospitalized for GIB. After the index hospitalization, patients were followed for resumption of DOAC (defined by new prescription fill), recurrent bleeding, and VTE. 62% of patients resumed DOAC therapy.

Resuming a DOAC within 30 days did not lead to a statistically significant difference in VTE or recurrence of GIB at 90 days or 6 months. However, at 90 days recurrent GIB risk increased with concomitant use of antiplatelet agents (hazard ratio, 3.12; 95% confidence interval, 1.55-5.81; P = .002). Rivaroxaban had higher rates of rebleeding events, compared with the other DOACs (P = .04). History of VTE increased the risk for postdischarge VTE. Key limitations included lack of cerebrovascular accident rates, exclusion of patients who switched from DOAC to warfarin, and uncertainty surrounding the timing of actual DOAC resumption.

Bottom line: DOAC resumption within 30 days of GIB did not increase VTE or recurrent GIB, but concurrent antiplatelet agent use increased recurrent GIB rates.

Citation: Sengupta N et al. Rebleeding vs. thromboembolism after hospitalization for gastrointestinal bleeding in patients on direct oral anticoagulants. Clin Gastroenterol Hepatol. 2018. doi: 10.1016/j.cgh.2018.05.005.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.

Clinical question: For patients who develop a gastrointestinal bleed (GIB) while using direct oral anticoagulant (DOAC) therapy for atrial fibrillation (AF), does the risk of venous thromboembolism (VTE) or recurrent GIB increase after DOAC resumption?

Background: DOACs are increasingly used for stroke prophylaxis in nonvalvular AF and can increase the risk of GIB by 30% compared to warfarin. Although warfarin can be safely resumed within 14 days of GIB cessation, outcomes related to resuming DOAC therapy after hospitalization for GIB are lacking.

Study design: Retrospective analysis of claims data.

Setting: Patients with AF on DOAC therapy admitted for acute GIB in Michigan.

Synopsis: 1,338 adults, median age 79 years, on a DOAC for AF were hospitalized for GIB. After the index hospitalization, patients were followed for resumption of DOAC (defined by new prescription fill), recurrent bleeding, and VTE. 62% of patients resumed DOAC therapy.

Resuming a DOAC within 30 days did not lead to a statistically significant difference in VTE or recurrence of GIB at 90 days or 6 months. However, at 90 days recurrent GIB risk increased with concomitant use of antiplatelet agents (hazard ratio, 3.12; 95% confidence interval, 1.55-5.81; P = .002). Rivaroxaban had higher rates of rebleeding events, compared with the other DOACs (P = .04). History of VTE increased the risk for postdischarge VTE. Key limitations included lack of cerebrovascular accident rates, exclusion of patients who switched from DOAC to warfarin, and uncertainty surrounding the timing of actual DOAC resumption.

Bottom line: DOAC resumption within 30 days of GIB did not increase VTE or recurrent GIB, but concurrent antiplatelet agent use increased recurrent GIB rates.

Citation: Sengupta N et al. Rebleeding vs. thromboembolism after hospitalization for gastrointestinal bleeding in patients on direct oral anticoagulants. Clin Gastroenterol Hepatol. 2018. doi: 10.1016/j.cgh.2018.05.005.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.

Clinical question: For patients who develop a gastrointestinal bleed (GIB) while using direct oral anticoagulant (DOAC) therapy for atrial fibrillation (AF), does the risk of venous thromboembolism (VTE) or recurrent GIB increase after DOAC resumption?

Background: DOACs are increasingly used for stroke prophylaxis in nonvalvular AF and can increase the risk of GIB by 30% compared to warfarin. Although warfarin can be safely resumed within 14 days of GIB cessation, outcomes related to resuming DOAC therapy after hospitalization for GIB are lacking.

Study design: Retrospective analysis of claims data.

Setting: Patients with AF on DOAC therapy admitted for acute GIB in Michigan.

Synopsis: 1,338 adults, median age 79 years, on a DOAC for AF were hospitalized for GIB. After the index hospitalization, patients were followed for resumption of DOAC (defined by new prescription fill), recurrent bleeding, and VTE. 62% of patients resumed DOAC therapy.

Resuming a DOAC within 30 days did not lead to a statistically significant difference in VTE or recurrence of GIB at 90 days or 6 months. However, at 90 days recurrent GIB risk increased with concomitant use of antiplatelet agents (hazard ratio, 3.12; 95% confidence interval, 1.55-5.81; P = .002). Rivaroxaban had higher rates of rebleeding events, compared with the other DOACs (P = .04). History of VTE increased the risk for postdischarge VTE. Key limitations included lack of cerebrovascular accident rates, exclusion of patients who switched from DOAC to warfarin, and uncertainty surrounding the timing of actual DOAC resumption.

Bottom line: DOAC resumption within 30 days of GIB did not increase VTE or recurrent GIB, but concurrent antiplatelet agent use increased recurrent GIB rates.

Citation: Sengupta N et al. Rebleeding vs. thromboembolism after hospitalization for gastrointestinal bleeding in patients on direct oral anticoagulants. Clin Gastroenterol Hepatol. 2018. doi: 10.1016/j.cgh.2018.05.005.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.